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LECTURES ON DIETETICS 



LECTURES ON 
DIETETICS 



BY 

MAX EINHORN 

Professor of Medicine at the New York Post- 
graduate Medical School and Hospital 
and Visiting Physician to the Ger- 
man Hospital, New York. 




PAUL B. HOEBER 

69 E. 59th Street 

NEW YORK 

1914* 



,E3 



Copyright, 1914, by 
PAUL B. HOEBER 



Published March 1, 1914 



MAR 30 1914 



©CI,A871103 



TO 

HIS DEAR AND HIGHLY ESTEEMED FRIEND 

COLONEL OLIVER HAZARD PAYNE 

this book is respectfully dedicated, in 

recognition of his great devotion 

to the art of medicine and 

to higher education. 



PKEFACE 

The edition of my monograph on Diet 
and Nutrition being exhausted I thought 
best to publish my lectures on diet which 
I usually deliver at the N. Y. Postgradu- 
ate Medical School in book form. They 
contain similar ideas to those expressed in 
the monograph. Moreover, they deal with 
a greater variety of subjects and express 
the more practical points. No attempt has 
been made to change the style or beautify 
the language of these lectures. They ap- 
pear here as taken down by the stenogra- 
pher. The reader has thus the advantage 
of the actual listener to this discourse. 

I hope that the present monograph will 
facilitate the question of diet to the prac- 
titioner and will aid him in its manage- 

ment Max Einhoen. 

New York, February, 1914. 



CONTENTS 

PAGE 

LECTURE I 
The Principles of Diet and Nutrition . .11 

LECTURE II 
The Digestibility of Foods, and the Diet in 
Health and Acute Diseases 30 

LECTURE III 
The Diet in Acute Diseases of Prolonged 
Duration and in Chronic Diseases ... 53 

LECTURE IV 
ihe Diet in Chronic Affections of the Diges- 
tive Tract 76 

LECTURE V 
The Dietetic Treatment of Chronic Diarrhcea 99 

LECTURE VI 
The Dietetic Treatment of Diabetes Mellitus 113 

LECTURE VII 
Diet Regimes 125 

LECTURE VIII 
Indications for and Description of the Method 
of Duodenal Feeding 135 



LECTURES ON DIETETICS* 

LECTUEE I 

THE PRINCIPLES OF DIET AND NUTRITION 

I propose to give a few lectures on the sub- 
ject of diet. Diet plays so important a 
part in health and disease that every phy- 
sician should be well informed on all points 
pertaining to it. It should really form 
the basis of every medical study. It is 
the A, B, C of medicine. We cannot live 
without food and we cannot treat anyone 
without a certain dietary ; and if we under- 
stand all the relations of diet a great deal 
can be accomplished by it alone in the 
treatment of disease, without the aid of 

* Lectures I, II, III and IV on Dietetics have been 
delivered at the Postgraduate Medical School and Hos- 
pital and have appeared in the Postgraduate Journal of 
July, August, September and October, 1913. 
11 



12 LECTURES ON DIETETICS 

medicine. Diet comprises all the ques- 
tions relating to food, and food forms the 
basis of all animal life. Food contains all 
the substances found in the living organ- 
ism, because the body develops upon it; 
it grows up from the little baby to the big 
organism. Nothing is added to the body 
excepting what is derived from the food. 

On the other hand, food contains only 
the substances found in the earth. Every- 
thing that we eat, animal or vegetable, 
originated in the soil under one form or 
another. That means that whatever we 
have in our bodies comes from the earth. 
The Bible says: "From earth you are 
made and to earth you go." Nowadays 
we speak of the different elements found in 
the body. We have analyzed the latter and 
know that there exist the most varied sub- 
stances: calcium, magnesium, iron, phos- 
phates, nitrogen, sulphur, etc.; but in the 
end the old philosophers were right. If 
we should take earth, even if we have all 



DIET AND NUTRITION 13 

the elements, carbon, calcium, phosphate, 
etc., we could not accomplish anything with 
it, but after these substances have been 
changed by living matter and developed in 
the forms in which they exist in either ani- 
mals or plants then it is fit for our organ- 
ism. It has first to undergo this radical 
change through living matter. 

Thus far we have not been able to ac- 
complish these changes artificially ; that is, 
we cannot put inorganic matter together 
so as to bring it into life. "We require an- 
other living medium to accomplish this 
change. Every living cell must originate 
from another one. So living plants de- 
velop from the seed into plants. There 
must first be something that is alive to 
bring forth new life. We know nothing 
yet of how inorganic matter develops into 
an organic being. It may be that the great 
chemists and physiologists think it origi- 
nated of itself, but we do not know about 
that for the present. So far as we can 



14 LECTURES ON DIETETICS 

tell, nothing is developed of itself, but ev- 
ery animate being is developed from some 
living individual. 

Our food, then, consists of either animal 
or vegetable matter. We find some na- 
tions living principally on animal diet, and 
some animals living on animal food exclu- 
sively; others live on vegetable material 
alone, and some nations live principally on 
vegetable food. That shows that either of 
the two is feasible, — that persons can live 
either on vegetable food alone or on animal 
food alone. If one should ask which is the 
better way, it is generally admitted that a 
mixed diet is the best for mankind. It has 
been shown that those nations which sub- 
sist on a mixed diet, taking both animal 
and vegetable food, have accomplished 
most in the way of progress. Those na- 
tions which live exclusively on animal diet, 
such as the Esquimaux, or the peoples to 
the far south where vegetable material is 
rare and who live almost exclusively on 



DIET AND NUTRITION 15 

the fish and animals which they hunt and 
kill have not accomplished very much in 
the way of progress. On the other hand, 
the peoples of India, China, and Africa live 
mostly on a vegetable diet, and these na- 
tions have not accomplished very much 
either, in the way of progress. It is pos- 
sible to live in either way, but as a whole, 
physiologists have decided that a mixed 
diet, combining the two forms of food ma- 
terial, is the best to develop the faculties to 
the highest degree. 

It has always been known that you can- 
not live without food; if you do not take 
in food, the body loses weight, and finally 
dies; but until recent years not much has 
been known of the exact amount of food 
required by nature to maintain life and to 
keep the body in good condition. The 
amount is almost mathematically pre- 
scribed, and in recent years this amount 
has been determined. This has been 
learned as follows: First, it has been de- 



16 LECTURES ON DIETETICS 

termined in a general way how much food 
grown persons require. It is noted how 
much one person, a second, and a third eat 
for breakfast, dinner, and supper. This 
is carefully written down, and then the 
average amount consumed is calculated, 
and so we know about what amount of food 
is required by normal persons in health. 
That gives a fair indication of how much 
is needed. 

Now, before going to the amounts re- 
quired, I will say a few words about the 
different classes of food. While every 
diet must contain all the elements neces- 
sary for life, the food has been divided 
into three large classes, because they all 
contain more or less of the elements neces- 
sary for life. These three groups are the 
proteins, carbohydrates, and the fats. All 
food contains one or two, or three of 
these substances. In order to find out the 
amount of food necessarily required for 
living, the physiologists have calculated 



DIET AND NUTRITION 17 

how much of these three different classes 
we require, not saying how much bread, 
meat, potatoes, etc, but how much albumin, 
how much carbohydrate, or how much fat 
is required for a grown person each day. 
It has been found that a grown person uses 
up each day about: 

120 gm. of albumin = oz. IV. 

500 gm. of carbohydrate = oz. XVII. 

60 gm. of fat = oz. II. 
2y 2 to 3 quarts of water. 

Water contains many mineral ingredi- 
ents not found in the food. While pro- 
tein must exist in the food which any indi- 
vidual requires for living, in some way or 
another, and cannot be dispensed with, 
either the carbohydrate or the fat can be 
omitted without much injury. This is to 
say, one of these groups can replace the 
other without injury to the individual for 
a while, but the albumin is essential. The 
reason for that is that the protein is the 
foremost substance in the body. Any tis- 



18 LECTURES ON DIETETICS 

sue that is used requires albumin to build it 
up again. The fat which is taken in helps 
to build up the organism; it also produces 
heat. Heat is also furnished by the other 
substances, by the protein and the carbo- 
hydrates, but as a tissue builder the pro- 
tein is necessary. From protein the or- 
ganism can make glycogen, fat, or muscle, 
but the body cannot make protein out of 
the carbohydrate or the fat. That is why 
protein is the most essential substance. 

Now the physiologists, especially Rub- 
ner — who was here not long ago — who has 
made a great many studies and deserves to 
be remembered, have tried to ascertain 
in what degree these substances can re- 
place each other, and found that they do 
it corresponding to the amount of heat 
which they develop. Every kind of food 
taken into the body is oxidized in the sys- 
tem. We take in oxygen with the air, 
and the nutritive substances become oxi- 
dized. The more carbon a special kind of 



DIET AND NUTRITION 19 

food contains, the more oxygen it can 
bind. The more carbon in the food, the 
more heat it can develop in burning 
up. The burnt up or oxidized compounds 
leave the body in the form of C0 2 and 
H 2 0, through the lungs and kidneys. 

It has been found that one gram (15 
grains) of food material, if oxidized (burnt 
up) develops a certain amount of heat. I 
will explain how that is calculated. It has 
been arranged by the scientists to measure 
heat in this way: The idea is to know ex- 
actly how to estimate the heat. They 
have agreed to take as the measurement for 
one heat unit the amount of heat which is 
sufficient to increase the temperature of one 
cubic centimeter of water (16 grains) 1 de- 
gree Celsius. This is also designated as 
a small calorie (cal.). 

In speaking of the heat values of food, 
however, we use great heat units, or great 
Cal. That means the amount of heat 
which is sufficient to raise 1 liter (1 quart) 



20 LECTURES ON DIETETICS 

of water 1 degree C. Returning to the 
food values, it has been found that one 
gram of protein is sufficient to develop 
4.1 Cal. In speaking of the food unit, we 
do not say " great heat unit," or great 
Cal., but we mean that. It is written Cal. 

Protein, 1 gm. develops 4.1 Cal. 

Carbohydrate, 1 gm. develops 4.1 Cal. 

Fat, 1 gm. develops 9.3 Cal. 

Notice that the fat develops more than 
double the amount of heat, as compared 
with the others. 

The way foods should represent each 
other is by their caloric value, excepting 
that we cannot eliminate protein. A cer- 
tain amount of protein must be in any 
food, — but we can combine protein with 
carbohydrate (as present in most vegeta- 
ble foods), or we can have protein and fat 
as represented by animal foods. If we 
should have someone live on protein and 
fat, we would say that the fat should be 



DIET AND NUTRITION 21 

less than half the amount of carbohydrate 
required, for it contains so many more 
heat units. 

Now it has been found that a man re- 
quires for one day about 2400 calories. 

A man doing a considerable amount of 
work ordinarily consumes about: 

Caloric value 
120 protein == 120 gm. X 4.1 = 492.0 

60 fat = 60 gm. X 9-3 = 558.0 

500 carbohydrate == 500 gm. X 4.1 = 2050.0 



3100.0 



It has been found generally that a grown 
person requires about 2500 heat units each 
day, or food which develops that number 
of heat units, when doing a moderate 
amount of work. If he works hard, he re- 
quires more, 3000 calories, or more. If he 
is in bed, he requires less. I have found 
that a patient in bed requires much less; 
he can exist on 1800 heat units without los- 
ing much flesh. 



22 LECTURES ON DIETETICS 



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28 LECTURES ON DIETETICS 

Food tables have been prepared indicat- 
ing how much albumin, carbohydrate, and 
fat each food article contains, and by using 
these you can know how much of each of 
these substances is contained in bread, 
meat, or vegetables and you can make out 
how many heat units they will develop. On 
the preceding pages will be found several 
tables of the composition of the most com- 
mon food substances, showing also the heat 
units they contain. (Tables 1-6.) 

Usually we find that all food articles con- 
tain two or three of these substances, 
proteins and carbohydrates, or carbohy- 
drates, fats, and a trace of protein, etc. 
Animal foods contain principally protein 
and fat; and the vegetable foods contain 
carbohydrates and protein and very little 
fat. 

On the whole, in the average diet, people 
take the greater amount of protein from 
animal food, and the greatest amount of 
carbohydrate from the vegetable kingdom. 



DIET AND NUTRITION 29 

The physiologists advocate taking a larger 
amount of protein from plants. Two- 
thirds of the protein ingested should be 
from vegetable food, and only one-third 
from animal food. In the majority of in- 
stances in this country and England this 
point is not heeded, and people take pro- 
tein principally from animal food, — eating 
meat three times a day. This is easy for 
the organism, as it is not bulky and can 
be eaten quickly. It is the most expensive 
article of food, but it is not always the best, 
and it is apt to bring on conditions which 
are not good, — gouty tendencies, and dis- 
turbances of the liver, etc. For healthy 
living, it is rather better to choose the pro- 
teins to a great degree from the vegetable 
kingdom. 

Next lecture our subject will be the di- 
gestibility of food, and we will see how to 
estimate the digestibility of what is eaten, 
and we will take up the subject of diet in 
health and diet in disease. 



LECTUEE n 

THE DIGESTIBILITY OF FOODS, AND THE DIET IN 
HEALTH AND ACUTE DISEASES 

We will start to-day with the subject of the 
digestibility of food. How can we estimate 
which food is easy to digest and which is 
not? When Beaumont had a patient with 
a gastric fistula, he thought he would find 
out about that. For at that time it was 
considered that the stomach was the main 
organ of digestion, and he thought that if 
food was found in the stomach after a long 
time it would indicate that the digestion of 
that food was not easy. On the other hand, 
he thought that if a certain article of food 
leaves the stomach in a short time, it would 
indicate that it was easy to digest. So, 
having this patient with a gastric fistula, he 
thought he would watch when the stomach 

30 



DIGESTIBILITY OF FOODS 31 

emptied after certain articles of food, and 
he made out a scale of the digestibility of 
food accordingly. 

In recent years, now that we are nsing 
the stomach tube so frequently, physician? 
do not need to have a patient with a fistula 
in order to watch the time when the food 
leaves the stomach, but can empty or wash 
out a stomach after a meal and examine its 
contents. This has been practiced by 
Leube, and later by Penzoldt. They took 
healthy individuals, medical students who 
were willing to take test meals and then 
have lavage practiced, or a tube introduced, 
to find out whether or not certain foods 
had left the stomach. Penzoldt has ar- 
ranged a table showing what time certain 
articles of food require for digestion in the 
stomach. 

Most physicians think that the shorter 
the time required for digestion in the stom- 
ach, the easier the digestion of that article. 
On further reflection, however, one can see 



32 LECTUEES ON DIETETICS 

that this is not a good gauge to go by. In 
reality, the main place for digestion is not 
the stomach, bnt the small intestine. The 
stomach prepares the food, but the actual 
digestion, for the greater part, takes place 
in the small intestine, and there the ab- 
sorption occurs. Many substances leave 
the stomach without any change at all — the 
fatty substances, for instance. According 
to my experience, the main place for the di- 
gestion of meat is not the stomach but the 
intestine. The muscle fibers become swol- 
len in the stomach, but they don't disap- 
pear. Connective tissue is one of the sub- 
stances that are absorbed in the stomach. 
Then, we have some of the starchy sub- 
stances which have already changed into 
sugar, which likewise are absorbed here. 
But everything else leaves the stomach, 
and enters the small intestine for further 
changes there. So the time the food re- 
mains in the stomach is not enough of a 
guide as to its digestibility. . 



DIGESTIBILITY OF FOODS 33 

Another plan of judging of the digesti- 
bility of food is to see whether it leaves a 
residue in the digestive apparatus or not — 
that is, whether it entirely disappears. If 
a certain article of food leaves a great deal 
of residue, and part of it passes through the 
entire digestive tract, it cannot be consid- 
ered very digestible ; while food that leaves 
no residue must be considered easy of di- 
gestion. So another scale has been made 
out according to that. 

As a general rule, we can say that all 
animal food leaves less residue and is, in 
a way, more digestible than all vegetable 
food. All vegetable food leaves more res- 
idue, no matter what it is : seeds, nuts, 
etc., those vegetable foods rich in protein, 
that come in prepared forms — flour, meal, 
— leave less residue than those materials 
which represent other vegetables, such as 
roots — like potatoes — or leaves and stems 
that contain a great deal of cellulose mat- 
ter; also most foods that grow on trees 



34 LECTURES ON DIETETICS 

contain a great deal of cellulose, which 
leaves a large amonnt of residue. 

Of animal foods, it has been found that 
those meats that contain less fat are easier 
of digestion than those that contain a con- 
siderable amount of fat. For instance, 
pork takes a longer time in the stomach 
and also leaves more residue than beef; 
so you have another point on which to 
judge of the digestibility. 

Another way of estimating the digesti- 
bility of food is by its physical character. 
All food before being absorbed must be 
changed into a liquid form. The organism 
cannot take up any substance unless it is in 
a gaseous or liquid form, or emulsified. 
Solid substances cannot penetrate the tis- 
sues. If we have to deal with foods that 
are liquid from the start, we can judge that 
their absorption will be much easier than 
that of solid substances which have to be 
changed into the liquid form. So you can 
make out a scale of the digestibility of 



DIGESTIBILITY OF FOODS 35 

foods according to their physical character- 
istics — whether or not they are easily 
changed into liquids. In this way we will 
have in that group which is more easily 
digested, or Group I, liquid food; milk, 
broths and gruels ; eggs beaten up in milk 
— emulsified — are easy to digest; also beef 
juice — the juice pressed out from the meat. 
Group II ; liquid at body temperature : fruit 
jellies and meat jellies, calves-foot jelly, ice 
cream that melts at body temperature, but- 
ter, all these are easily digested. 

Group III. Foods that are easily broken 
up into fine particles beforehand, such as 
mashed potato ; or where some mechanical 
movement is necessary to divide the food 
into fine particles, already prepared, 
mashed, etc., powdered meat, all mashed 
vegetables, purees ; soft boiled and poached 
eggs belong to the same group ; bread and 
crackers dried and pulverized, toast and 
bread cut up or ground up nicely and put 
into some liquid. 



36 LECTURES ON DIETETICS 

Group IV. Foods that are not easily 
broken up, but still change easily and do not 
present too much resistance to mechanical 
division, such as bread, boiled potatoes and 
vegetables not made into purees; foods 
such as sweetbreads, calves' brains, and 
fish are a little lighter than other kinds of 
meat, like chicken and chops, and are easier 
to mash up and chew. 

Group V. Where the division is a little 
harder. Here we have the meats that have 
stronger fibers. Boiled lobster does not di- 
vide up so quickly as tender meat; fruits, 
where a great deal of chewing is required to 
break them up. 

Group VI. This is the hardest group — 
salads and raw vegetables, cheese, and 
foods that contain a great deal of sulphur 
— such as cabbage, etc. 

According to these lines you can see 
whether a food is easily digested or not, 
and if you act according to this scale you 



DIGESTIBILITY OF FOODS 37 

will see that it corresponds with the other 
scales mentioned before. 

Now, speaking about diet in health, is it 
good for healthy persons to abstain from 
food substances that are not easily digest- 
ible? There are a great many persons 
who think that if they avoid all kinds of 
hard foods, and live on the finest articles, 
milk, eggs, soups, etc., they are better off 
and do not get sick, but in my opinion that 
is not the right way to live. It is rather 
advisable to harden the system. If you 
live on only light diet for some time, and 
then on some occasion have to take some- 
thing else, you are liable to get sick; the 
digestive tract is not accustomed to it. In 
normal conditions, it is best to have a lib- 
eral diet and not to select foods that are 
easily digestible. You should rather mix 
your diet; take some substances that are 
more difficult to digest, and accustom your- 
self to a variety of food. If a man has 



38 LECTURES ON DIETETICS 

accustomed himself never to take salads 
and once in a while has to take some raw 
foods, he is likely to get sick and need some 
medicine. People in health should have 
a liberal diet, and should include some sub- 
stances that are not so easily digested. 

Should people eat fast or slowly? Here 
again the golden rule is in the middle. The 
food should not be eaten too fast, nor yet 
too slowly. One reason for that is that if 
you eat too slowly and are used to it, and 
then some day have to hurry and take a 
meal a little more quickly, you will get sick. 
Again, if your appetite is not so good, and 
you are used to eating slowly, you will get 
tired of your food and stop in the middle 
of a meal. I have found that severe con- 
ditions develop sometimes from eating too 
slowly, especially in persons who are not 
so well. They are imbued with the notion 
of eating slowly, and counting so many 
times before swallowing; they grow tired 
of eating, and their appetites are not good, 



DIGESTIBILITY OF FOODS 39 

and instead of eating a good dishful they 
eat only a few mouthfuls ; so they are not 
well nourished, and become nervous, etc. — 
all due to that habit of slow eating. 

Fast eating, also, is not good. Some 
very disagreeable conditions develop from 
swallowing the food too quickly, not chew- 
ing it up and masticating it properly. It 
may go on for a while without apparent 
harm, but after a while some disagreeable 
conditions develop, perhaps some catarrhal 
condition or a functional disturbance of the 
digestive apparatus. So take time for your 
meals, but do not overdo it. Live sensi- 
bly and have a good meal, and have a lit- 
tle conversation with your meals, and 
have to wait for one dish and then another. 
Once in the country I asked a lady to go 
out for a ride with me. She said: "Be- 
fore I go, I would like to have a glassful 
of milk." I said: " Certainly. ' ' But 
instead of taking a glass of milk and 
drinking it, she sipped and sipped, and 



40 LECTURES ON DIETETICS 

took a half hour to drink the milk. She 
suffered from headaches, and then she be- 
came my patient. She consulted me, and 
I knew right away what was wrong. I 
tried to convert her to another way of liv- 
ing, and succeeded, and she is much better 
off now. That was an instance of the evil 
of slow eating, and how I discovered the 
cause. 

How many meals should a normal per- 
son have? Should we eat twice a day, 
three times a day, or five times a day? 
There are people who do all of these ways 
and enjoy perfect health. This question 
cannot be answered off-hand. I think the 
customs of the country in which one lives 
are the best guides to follow. Here in 
America, people eat three times a day, as 
a general rule — a good breakfast, a good 
supper — morning and night. At noon time, 
they are away from home, and have only 
a light luncheon. Two good sized meals 
and one small one between. The reason 



DIGESTIBILITY OF FOODS 41 

for that is that they are not at their homes, 
are far away, and have to be satisfied 
with a little something at the business 
hour — so that is the best for them. They 
have their heavy meals at home, prepared 
to suit them, and in the middle of the day 
they take something to meet the require- 
ments. People in the country, or who are 
at home and do not have to leave the house 
for their meals, usually have a smaller 
meal in the morning, take a good luncheon 
or dinner in the middle of the day, and 
have another small meal in the evening. 
Usually the morning meal is the smallest, 
the one in the middle of the day is the lar- 
gest, and the second in size is the supper — 
so for them, that is all right. In Ger- 
many, they are used to taking a very small 
breakfast — only coffee and a roll. They 
eat no eggs then, but they have another 
breakfast at ten o'clock or half -past ten. 
Prof. Virchow used to lecture at 11 o 'clock, 
and he came into his lecture room about 



42 LECTURES ON DIETETICS 

half after ten and had a sandwich and a 
glass of beer. That was his regular cus- 
tom. That is their way. They take 
something in the morning, and then some- 
thing additional a little later; then have 
luncheon, and again something in the aft- 
ernoon at half-past three — coffee, with a 
little bread. They have more time there 
and are more sociable. They go to the 
cafes and restaurants, and spend some 
time there, and have a little chat, and then 
go on their way. "Whether you like it or 
not, that is an easy way. Then they take 
their supper, and go out again, and later 
in the evening they go to a beer garden, 
and take a bite again. So they eat per- 
haps six times a day. That is not oblig- 
atory, but it is customary, and it is all 
right. It has a tendency to fatten them 
up. On this account you perhaps find 
more fat people in Bavaria, and Germany, 
than here. That used to be the way when 
I lived there, and it is an easy way of liv- 



DIGESTIBILITY OF FOODS 43 

ing. Frequent eating and doing less 
work tends to corpulency, and that is what 
we find. In this country corpulence is 
not a frequent disease. Not one of you 
here has that characteristic. The differ- 
ent mode of living and eating is the rea- 
son for it. In Europe, you might find half 
a dozen or more fat persons among such a 
number. 

The best way is not to change the cus- 
tom of the country, but to do what others 
do. The majority rules. Don't try to do 
better than the others. Go along with 
them and you will be all right. That is 
the best rule. 

Diet in Disease. We may for our pur- 
pose divide all diseases into two classes, 
for in these groups the diet is quite differ- 
ent. One, in which the disease is of an 
acute character and lasts only a short 
while. In the second group, we have to 
deal with chronic conditions, or diseases 
lasting over long periods. 



44 LECTURES ON DIETETICS 

We will start to-day with the diseases 
of short duration. Here the main point 
is to see that the digestive tract is not bur- 
dened with much work. The principle of 
rest plays the greatest part in any dis- 
ease, especially in regard to diet. In any 
disease, no matter what — of the stomach, 
liver, kidneys, lungs — the organism re- 
quires rest. You have, for instance, a pa- 
tient with pneumonia. He has been all 
right, right along, but now he is attacked 
with pneumonia. Here it would be wrong 
to prescribe plenty of nourishment. He 
does not need it, and you would only make 
him worse if you force him to take food. 
Nature has provided for that, and gives 
hints in regard to the method of proced- 
ure. When a man is taken sick, he sud- 
denly loses his appetite and has an aver- 
sion for food, and tells you to leave him 
alone. That is what nature does, and it 
is the correct way. His body is in good 
nutrition, and no harm is done if in that 



DIGESTIBILITY OF FOODS 45 

period of sickness — which usually lasts 
from three to six or seven days — he does 
not have food. His organism has enough 
material in it to utilize during that period 
of emergency. It is rather best to act on 
the principle of rest and not to burden the 
system with food that is not essential. 
Keep such a patient quiet in bed, with 
cold ablutions of the body or something 
of that sort; and left alone, the organism 
has a good chance to fight the disease. 
This principle prevails everywhere in all 
diseases. The patient may lose say eight 
or ten pounds during the disease, but as 
soon as the period of fever or the acute 
stage is over, the appetite will come back, 
the patient is hungry — even more so than 
formerly — he eats more and quickly re- 
places what was lost. 

But while it is not essential to introduce 
much food into the organism during the 
period of acute illness, it is essential to 
look out for the amount of fluids in the 



46 LECTURES ON DIETETICS 

system. You must not say: "Give the 
patient nothing " — that is wrong; but you 
must see that he gets enough water. That 
is a very important point. The reason 
for that is that a man in good condition — 
a normal individual, a healthy man — 
if deprived of food but supplied with wa- 
ter, can live for twenty or thirty days 
upon the material supplied from the body. 
There are professional starvation men 
who practice that, and have been able to 
live thirty or forty days on water alone — 
using their bodies to live upon. At the 
end of that time, they resume eating and 
are again all right. 

If in addition you take away water, how- 
ever, the period of life is shortened. One 
can live only three or four days at the ut- 
most without water. Why cannot a man 
live a little longer? He has enough in his 
body to live upon; there is enough flesh 
and fat in the body to live upon, and yet 
he dies. The reason for that is that there 



DIGESTIBILITY OF FOODS 47 

is a shortage of water, of fluids, in the 
system. We use up a great deal of fluid, 
by respiration, perspiration, by excretion 
through the kidneys, etc. We lose at least 
two or three quarts of fluids daily in this 
way. If it is not there, the organism 
takes it from the fluids in the system, the 
tissues dry up, the blood thickens, and 
the man dies. In two days we lose six 
quarts, that is twelve pounds from the flu- 
ids. Then what happens ? There is plenty 
of nutritive substance in the organism, 
but the blood has become thickened, the 
capillaries cannot work, the substances 
which are in the system cannot replace 
those which are needed, the traffic is cut 
off, the rivers are dried up, the vessels 
cannot go, and the man dies. He dies not 
so much from lack of food material as 
from lack of fluids. 

In the acute diseases, the loss of fluids is 
increased. During fever a patient, in- 
stead of losing three quarts of fluid a day 



48 LECTURES ON DIETETICS 

loses four or five. If you do not see that 
the patient drinks, or that something is 
given him to replace the loss very quickly, 
there will be something wrong. So, while 
it is not necessary to introduce much food 
into the system during an acute illness, 
the necessity of introducing fluids is in- 
creased. 

There is another reason why fluids are 
essential during the acute stage of dis- 
ease. In most instances we have to deal 
with infections, and there are toxic sub- 
stances developed through the system by 
bacterial action. These have to be re- 
moved from the system, and we can do this 
quickly if we flush the system. Give them 
more water than they need. They have 
to pass more water, and the water must- 
reach the circulation first before it is car- 
ried off, and that washes out the system. 

I will give you one instance of this, for 
I think that those things which really oc- 
cur impress us more than anything else, 



DIGESTIBILITY OF FOODS 49 

so I will tell you of something that hap- 
pened to me. When I was a little boy, I 
was in Russia, visiting some relatives, and 
cholera developed there. They were anx- 
ious to send me home, as was quite natural, 
and the carriage was waiting for me down- 
stairs, so I put on my overcoat ; but while 
I was getting ready to go down, I 
collapsed and was attacked with the chol- 
era, and became unconscious, vomited, etc. 
I had the real Asiatic cholera, so I was 
put to bed. I could not talk, could not do 
anything. There were several physicians 
in attendance, and they thought I was go- 
ing to die. They did not give me any- 
thing; at first I was kept without any- 
thing, but when I returned to conscious- 
ness I was very thirsty, as was quite nat- 
ural, but the two physicians thought dif- 
ferently. They called in a third physi- 
cian, and he said "Give him water; if he 
is thirsty, let him drink." So they put a 
big pitcher of water next to my bed, and I 



50 LECTURES ON DIETETICS 

emptied it once, a second, a third time. 
I was drinking all the while. After a 
period of a week or ten days, during which 
I was almost dead, I began to recuperate, 
and yon see I am still living. I think 
that water saved my life at that time. I 
am quite sure that if it had not been given 
to me I would not have had a chance of re- 
covery. I want to impress upon you the 
necessity of giving liquids. If a patient 
is thirsty, let him drink. But supposing 
he is not thirsty, is apathetic, does not 
want anything, lets himself go. Is it nec- 
essary to remind him? I think it is. 
You must look out, even then. The fluids 
should be given; he should be encouraged 
to drink; give lemonade, Apollinaris wa- 
ter, barley water, etc., make him drink. If 
you cannot accomplish that, introduce the 
water into his system in some other way; 
through the bowels is a very good way. 
Give him saline injections. If he does not 
keep that and is very weak, and does not 



DIGESTIBILITY OF FOODS 51 

drink, and there is need of fluid, you can 
give injections subcutaneously, under the 
skin, but see that; there is enough fluid in 
the system, especially in such conditions 
as diarrhoea, vomiting, etc. 

The principle of introducing liquids into 
the system to cover the loss from perspi- 
ration, etc., is of the greatest importance. 
While, as I have said, it is not essential to 
look out for the nourishment of patients 
in these acute illnesses, there are excep- 
tions to this rule. For instance, you may 
have to deal with an elderly individual, 
say a patient of seventy or seventy-five. 
Usually such patients are not so very well 
nourished, people of this age usually grow 
thin, and cannot stand much loss, and there 
we cannot neglect to pay attention to the 
food, even in that short period, but see 
that they take food that is easily digested. 
Give them milk, say every two or three 
hours, decoctions of barley water, etc. 
Long ago Hippocrates understood this, and 



52 LECTURES ON DIETETICS 

gave his patients the ptisan, which is a de- 
coction of barley water and sugar. Sugar 
is a good nutritive material. He treated 
febrile cases by cutting off food and giving 
them barley water and honey. 

For the next lecture we will take up the 
second group of diseases, and we will con- 
sider first the subject of diet in more pro- 
longed acute diseases, such as typhoid fe- 
ver, etc. 



LECTUEE III 

THE DIET IN ACUTE DISEASES OF PROLONGED 
DURATION AND IN CHRONIC DISEASES 

Proceeding with the subject of diet, we 
will to-day take up the question of diet in 
typhoid fever, which is one of the acute dis- 
eases that often lasts for a long period of 
time, and requires special attention. In 
former times, up to about seventy-five 
years ago, it was the tendency of the med- 
ical profession to withhold nourishment 
from patients with typhoid fever and to 
give them as little as possible, and that 
little only in liquid form. The teachings 
of Hippocrates prevailed especially with 
regard to this terrible disease, and these 
patients would get only a little weak tea or 
barley water; even milk was kept away 
from them as it was considered a form of 

53 



54 LECTURES ON DIETETICS 

nourishment which might disturb them 
too much. So the starvation plan was 
carried out in this disease also, up to the 
time of convalescence. 

The renowned clinician, Dr. Graves, of 
Great Britain, was the first one to try to 
introduce some reform in the treatment 
and management of typhoid fever in re- 
gard to diet. He thought that the starva- 
tion method was not a good way to treat 
these patients and that perhaps a great 
many of them died from lack of nutrition 
— not so much from the fever as from the 
lack of nourishment — the body being una- 
ble to fight the disease. So he thought he 
would give these patients light nourish- 
ment, and he gave them milk, which is a 
liquid food that is easily digested. He 
was the first one to make use of milk in the 
dietary of typhoid fever in a considerable 
degree — to give them a good amount of 
milk. That theory was combated by the 
clinicians of that day; many thought that 



ACUTE DISEASES 55 

he killed his patients, and like all innova- 
tors he had a great many enemies. The 
profession was not ready to accept the 
great change of giving milk to patients 
with typhoid fever. Graves fought his 
battle, however, and finally carried it 
through. In the meantime, many physi- 
cians more and more adopted his plan. 
Dr. Graves was so proud of this reform of 
introducing milk into the diet of typhoid 
fever that in his will he left directions 
that his tomb should be inscribed: "He 
fed fevers. " 

That was the first article of food that 
was added to the dietary of typhoid fever 
patients for many years; they were kept 
on a diet consisting of milk, broths, and 
gruels. Then came another current from 
Eussia. There are a few clinicians there 
who tried giving typhoid fever pa- 
tients an ordinary diet, solid food — any- 
thing. I do not remember the name of the 
man who first introduced this treatment, 



56 LECTURES ON DIETETICS 

but at any rate some of the physicians 
took up the plan of treating these patients 
with the ordinary food — bread, meat, and 
vegetables — and still they reported results 
that were not worse than if the patients 
were treated with very fine food in their 
diet. They claimed that their patients 
thrived, felt stronger and better, and got 
over the disease just as well. Now, you 
will ask, what shall we do? 

In my opinion, we should not give the 
patient the ordinary daily food. That 
would be too radical a change. But their 
experience has shown that we need not be 
too much afraid of introducing a little 
more food into the dietary of these pa- 
tients, and that typhoid fever patients 
need not always be restricted to strictly 
liquid food. We may give them a semi- 
solid diet, and perhaps in some cases may 
give a little solid food. 

Now another point has emanated from 
this country. I think the beginning of 



ACUTE DISEASES 57 

this was in Germany, but it was not car- 
ried out to the extent to which it has been 
followed out in this country. A great 
many years ago, Prof. Leyden, of Berlin, 
who has done so much for the dietetic 
treatment of diseases, was of the opinion 
that with typhoid patients, or any patients 
with fever who lose so much flesh, we 
might by increasing the nourishment, be 
able to check the loss. It has been for 
quite a while a subject of controversy as 
to whether this could be done. In such 
fevers, the expenses of the body are in- 
creased and the intake is diminished, and 
it was a question as to whether the diges- 
tive system would be able to take up the 
food, which would balance or outbalance 
the loss. That question had not been de- 
cided until Dr. Warren Coleman of this 
city took it up and carried the point 
so far as to prove that you can give a ty- 
phoid fever patient enough nourishment 
to prevent him from losing flesh. Some- 



58 LECTURES ON DIETETICS 

times you can even make him gain during 
the febrile period. It is, therefore, only 
a question of the quantity of nourishment 
introduced, whether he loses or not. Dr. 
Coleman of Bellevue Hospital really did 
a great deal of meritorious work in this 
line. 

Some years ago I tried to nourish some 
of these patients in the German Hospital, 
giving them larger amounts of food. We 
gave them milk and added raw eggs — 
three or four a day, beaten up in the milk 
and strained. Dr. Coleman gives still 
more. He adds cream to the milk, in- 
creases the liquids and gives sugar of milk 
—that is, sugar that is not so sweet. It 
can be put in the milk or in lemonade and 
makes a very agreeable drink; and at the 
same time increases the amount of nour- 
ishment, as it contains a large amount of 
carbohydrate. If you give a tablespoon- 
ful of lactose you have sixty calories, and 
you can put two tablespoonfuls in a glass 



ACUTE DISEASES 59 

of lemonade or milk and thus furnish 120 
calories. If yon give eight ounces of milk 
with two tablespoonfuls of lactose, and 
give that eight times a day, yon get a fair 
amount of fluid of nutritive value. Dr. 
Coleman also gives his patients eggs, fa- 
rina, rice, and toast. He is not so careful 
in abstaining from solid food, and gives 
practically a liquid and semi-solid diet. If 
milk is not well-borne, we have to give 
other things, barley, broths, and eggs, and 
so have a good variety. 

Last fall I had a patient from out of 
town with typhoid fever. He had lost 
twenty pounds of flesh and had headaches, 
but no one had made a diagnosis of the 
condition. He came to me for a diag- 
nosis, for everyone thought he had some 
stomach trouble. He complained of in- 
digestion and his appetite was poor. He 
was kept in the hospital under observation 
for a day or two, and we found that he 
had some temperature, and then the diag- 



60 LECTURES ON DIETETICS 

nosis was easy. His previous examina- 
tions had been made at a very early stage. 
In that beginning period before he had 
high fever, he had lost twenty pounds. 
When he came into the hospital he said 
that he could not stand milk, that it disa- 
greed with him. So I started him on 
plenty of lemonade with milk sugar, and 
gave him eight or ten eggs a day beaten 
up with barley decoctions, and butter in 
addition. That man did not lose another 
pound during the entire course of his ty- 
phoid fever. As soon as the fever was 
over the nourishment was pushed further, 
and he gained right away, and we sent him 
home with a gain of fifteen or twenty 
pounds. That was an example of what 
can be done with diet in typhoid fever for 
a patient who cannot stand milk. If he 
had been able to take that, it would have 
been still easier to give him nourishment. 
In typhoid fever, too, on account of the 
length of its course, see that the patient 



ACUTE DISEASES 61 

takes food say every two hours. Give 
him lemonade, grapefruit, good chicken 
soup, a little ice cream — that is very re- 
freshing and good. The same principle 
will apply to diseases of any duration ac- 
companied with fever. 

Now we will take up the diet in chronic 
affections not accompanied with fever. 
The principle which prevails here is just 
the reverse of that adapted for diseases of 
acute and short duration. In those we 
said that we need give no attention to the 
amount of nourishment taken. It does 
not matter that the patient takes no food 
for a short time; he will get over the dis- 
ease quickly. In diseases of a chronic na- 
ture the first principle is to see that the 
patient takes enough nourishment; for un- 
less he gets sufficient nutrition it does not 
matter what else you may do — the diet 
may agree, the medicine, etc., be just right 
— but the patient will go down. He is 
bound to lose. He grows weaker, and 



62 LECTURES ON DIETETICS 

finally succumbs not so much to the dis- 
ease as to subnutrition. No matter what 
type of disease they have, they will get 
tired of the diet. If you do not pay a 
great deal of attention to them, and espe- 
cially if the diet is restricted too much — 
say milk and eggs, and chicken soup, and 
nothing else — in a week or two they get 
tired of it, and do not enjoy it, and the 
tongue gets coated, and they take less, and 
grow weaker. So you have to see that 
you give the patients enough nourishment. 
This principle comes first in the plan of 
treatment, no matter what the disease is. 
If you have to deal, for instance, with 
tuberculosis patients, who form a large 
class of these chronic sufferers — if you are 
not attentive in seeing that they take nour- 
ishment, — they will take less and less ; they 
have a little fever off and on, and may 
have some catarrhal condition of the stom- 
ach or some catarrh of the bowels and not 
feel like eating. They are in a state of 



ACUTE DISEASES 63 

starvation, and very often they succumb 
to that. I will tell you of a case to show 
what can be done with proper nutrition 
in these cases. I was once called to a 
patient, a lady with lung trouble, who had 
suffered with diarrhoea. Almost anything 
she took caused the bowels to move right 
away. The treatment she had been having 
consisted in keeping from her all kinds 
of food. She had only a little warm broth 
and perhaps two eggs. She had lost a 
great deal of flesh and looked like a skele- 
ton, and had high fever, and the question 
was what could be clone for her. When I 
got there I saw that she would die in no 
time, two or three weeks, perhaps, unless 
the plan of diet was changed. So I said 
we must give her nourishment, diarrhoea or 
no diarrhoea. We must put in food. It is 
better to put in and lose something, than 
not to put in at all. So we began to feed 
her. We gave her six or eight eggs a day, 
farina with milk, rice with milk; and in a 



64 LECTURES ON DIETETICS 

few days we started in with meat and 
mashed potatoes, and we fed her five or 
six times a day. She had a nurse to watch 
her and push the feeding, and make her 
take the food ; and by and by she began to 
rally, and in a short while she lost her tem- 
perature, and her bowels were better, and 
she began to go out, and gained thirty or 
forty pounds, and it was three or four 
years before the lung trouble again as- 
serted itself and she died. 

If there is subnutrition existing, you 
have to step in and work against it. You 
may say that the bowels are weak and can- 
not stand anything. You must try. I 
do not mean to say that you should not 
give any remedies. That lady, besides 
the diet treatment, had some remedies to 
bridge over the symptoms. If there is 
diarrhoea, we will give them some tannigen, 
bismuth, and a little codein, but they must 
eat at the same time. 

It is very much the same in other 



ACUTE DISEASES 65 

chronic conditions — gout, chronic rheu- 
matism, chronic Bright 's disease — which 
is a very common complaint. Here the 
diet is often too one-sided. A great many 
physicians give milk and milk alone in 
kidney troubles because, as you know, the 
kidneys are not able to keep back albumin 
and make use of it ; and the principle is to 
keep away the proteid foods as much as 
possible in order to save the organ. But 
if the diet is too one-sided, if the patient 
takes too little and does not enjoy it, he 
suffers from inanition, which is worse than 
the disease. 

In these chronic diseases you can pay at- 
tention in the plan of treatment to the 
work of the organ, to its function, to see 
that its diet should not be too heavy for 
the particular patient. In kidney trouble 
you will try to eliminate the protein to 
some extent; give only a little meat, but 
the principle should not be carried to the 
extreme; you must give in a little and 



66 LECTURES ON DIETETICS 

adapt the diet in such a manner that there 
will be a variety in the food, and the pa- 
tient will enjoy it. Give them all the ce- 
reals and breads and a little meat. Re- 
strict the particular article that you do 
not want, but do not cut it out entirely. 
The same way with diabetes mellitus — or 
sugar disease. We know that sugar is not 
well-borne; the system cannot use it up, 
and eliminates it through the kidneys. 
So, as a rule, we put these patients on 
animal diet, and cut off starchy foods; 
but if you take these away entirely the pa- 
tient gets tired of the animal food and 
grows weak and runs down. Most physi- 
cians to-day agree that it is well to give 
them a little starchy food; the system is 
better off with a mixed diet; but restrict 
the undesirable kind. Give them only 
two rolls a day. 

A restricted diet can be carried out with- 
out harm for a short period of time. You 
may institute a milk diet for a r week or two 



ACUTE DISEASES 67 

without harm, but to carry it on too far 
is always a mistake. The system is apt 
to suffer from a one-sided diet, no matter 
what the disease is. 

After these points on diet in chronic dis- 
eases, we will go on to the diet in diseases 
of the digestive tract. With these, on the 
whole, the same principles prevail as in 
the other diseases. Acute conditions re- 
quire little attention to diet. The diet 
should consist of the finest foods in liquid 
form and in small quantities. We do not 
have to look out for large amounts to cover 
the loss, and we act on that principle. 

Acute indigestion, for instance. Some 
one has taken too large a dinner, has fever, 
and vomits. What will you do with the 
patient? The best thing is to do as little 
as possible. Leave him alone. He has no 
appetite, and does not eat for a day or 
two. That is all right. There will be no 
bad consequences. In a day or two the 
bad condition will be over and he will be- 



68 LECTURES ON DIETETICS 

gin to eat again. If, however, the patient 
is in a much reduced condition, and not 
well nourished, you will have to give some 
nourishment — clam broth, milk, tea and 
sugar. Give them light nourishment, and 
they will get better. 

The same obtains in diseases of the 
bowels — for instance, in severe diarrhoea. 
Leave the patients alone. Give them a 
little tea, warm soup, until the acute at- 
tack has subsided, and then begin to nour- 
ish them again. 

The chronic diseases of the digestive 
tract may be divided into two large groups 
— one in which there is organic disease 
present, like ulcer or cancer; and the other 
in which there are mild inflammatory con- 
ditions, catarrh, etc., or functional disturb- 
ances present. 

In regard to organic disease, ulcer of 
the stomach, for instance, there we make 
a division between the two stages — the 
acute state of the ulcer where there are 



ACUTE DISEASES 69 

more pronounced symptoms, severe pain 
and vomiting; and the chronic stage, the 
period of acquiescence, where the condition 
is not so active. The treatment must be 
different in the two periods. In the acnte 
stage, again rest is the principal thing. 
If the patient has a hemorrhage, keep him 
on rectal alimentation — practically starva- 
tion, and saline injections; some of the 
fluid is taken np by the system; perhaps 
one-third or a quarter of the nutritive 
material introduced through the bowel can 
be taken up, but it is essential that the di- 
gestive tract should rest for five or six 
days. Then begin with mild liquid diet 
by mouth, or duodenal feeding. That 
represents a method of feeding which cov- 
ers the losses and gives rest to the stom- 
ach. 

But when the acute stage is over and 
the chronic form has begun, then you have 
to look out for a sufficient amount of food. 
The food should not, however, be too ir- 



70 LECTURES ON DIETETICS 

ritating to the system. In cancer of the 
stomach we have to look out that the pa- 
tient is well nourished, and we give him 
fine articles of food, and if it is impossible 
to put the food in the stomach normally, 
as in cancer of the pylorus, a gastroenter- 
ostomy is done to make nourishment pos- 
sible; but again we have to see that the 
food given does not irritate the particular 
disease. A patient with cancer cannot 
stand the ordinary food, but we have to 
give him as much of a light food as we 
can, and as long as we can. 

In the second group of cases, the func- 
tional diseases of the stomach and intes- 
tines, it is very important to feed them 
properly. Formerly the principle pre- 
vailed that all dyspeptic individuals should 
be put on a diet, and by that was meant 
very little of the finest food — a milk diet, 
or soup, or perhaps a little meat. There 
was a physician in the city who used to 
give his patients meat and broth, and per- 



CHRONIC DISEASES 71 

haps a few slices of toast — nothing else; 
and that particular diet was carried out 
with a great many patients, sometimes 
with some benefit, but oftentimes with a 
great deal of harm. In Germany to-day 
that theory of dieting a patient still pre- 
vails, more so than I like. I often have 
such patients come to me, and I tell them 
to go ahead and eat like other people, only 
to exclude this or that ; and by and by they 
come to me and ask if they should not be 
put on a diet, — meaning to be kept away 
from food. But in my opinion, that is the 
worst thing for them to do. 

It is my conviction that the princi- 
ple that prevailed in former years — 
of putting every patient with dys- 
peptic symptoms on a restricted diet — 
was a wrong one. A great many persons 
who suffer from minor ailments of the 
digestive system keep away from food. 
Many physicians think that starchy foods 
are harmful for such patients, and forbid 



72 LECTURES ON DIETETICS 

them to take bread and potatoes. All vege- 
tables contain starchy food, so they are 
allowed only a little bread and perhaps 
only a little meat, and they do not enjoy 
their food, and symptoms of inanition de- 
velop, and many of these invalids ulti- 
mately die of improper feeding. 

The proper principle is not to forbid 
anything but what is sure to cause harm. 
Everything else should be allowed. These 
patients should be given great liberty in 
their diet, because it is of the greatest im- 
portance to look out that these chronic 
dyspeptics get a sufficient amount of food. 
That is the principle upon which I act, and 
the more I practise it the more am I con- 
vinced that it is the right way of treating 
these patients. 

One of my patients was a physician 
from Texas who had some dyspeptic trou- 
bles, and he got worse and worse, until he 
had lost forty pounds of flesh, and finally 
had to give up his practice on account of 



CHEONIC DISEASES 73 

his inability to take food. He came to 
this city, where he had a good friend, 
a nerve specialist, who invited him to stay 
with him at his summer residence in 
Greenwich and offered to look after him; 
but the man continued to grow worse. He 
could not take any food, and still lost flesh, 
and having had to give up his business he 
was constantly worrying, and his nervous 
symptoms did not improve. Finally he 
came to me for advice, and began by tell- 
ing his story. He could not take any 
toast, for that caused symptoms right 
away ; he could not take meat, for it made 
him vomit; he could not take that, for it 
gave him a headache, and so on — he could 
not take anything. He thought that I was 
going to be guided by his opinion, but he 
was mistaken ; if I had done that, he would 
be dead now. I told him that if he wanted 
to be treated by me, he would have to do 
as I directed, and leave his own opinions 
alone. So we began. His disease as such 



74 LECTURES ON DIETETICS 

did not amount to much. He had an 
atonically dilated stomach, and was in a 
run-down condition, but had no organic 
disease. We began to feed him, and I 
had to make him eat contrary to his own 
convictions. I had to give him bromides 
at first, to act as a sedative, but he did as 
I said, and began to eat, and he regained 
his flesh, and is now practising as before, 
and is convinced that he can eat everything. 
A great fear of food — "sitophobia" — 
develops in many of these dyspeptics, per- 
haps because of some disturbances they 
had experienced and because they have 
been told to keep away from all kinds of 
food, and when they do take it that fear 
gives them more symptoms, so that the 
patient is worse if he has to eat something ; 
he is afraid to sit at the table, and cer- 
tainly he must suffer. That condition 
must be combated — the aversion to the 
sight of food. You must tell them that 
even if there is some pain, they must take 



CHEONIC DISEASES 75 

the food and get out of that condition. It 
is better to eat and suffer than not to eat 
and not to suffer. You cannot live with- 
out food. That is the first and foremost 
principle. 



LECTUEE IV 

THE DIET IN CHRONIC AFFECTIONS OF THE 
DIGESTIVE TRACT (CONTINUED) 

To-day we will continue with, the subject 
of diet in the treatment of diseases of the 
digestive organs, of a chronic nature. I 
mentioned in my last lecture that severe 
illness and organic affections have to be 
treated differently in regard to diet from 
those troubles which are more or less of a 
functional character, and which are in the 
majority. 

We will subdivide this large class of 
functional disturbances, taking the stom- 
ach first, into three divisions : — one in 
which the gastric secretions are increased 
(hyperacidity) ; the second, in which gas- 
tric secretions are normal, and third, in 
which they are diminished (hypoacidity). 

76 



CHEONIC AFFECTIONS 77 

In hyperacidity — too much acidity, too 
much gastric juice — we again have several 
subdivisions: One, continuous hyper- 
secretion and the other, increased secre- 
tion during digestion, i. e., digestive hyper- 
secretion. 

The second large group is that of rather 
normal secretion and the third, is dimin- 
ished secretion, or absent secretion. We 
have to deal with all of these conditions. 
First, we will take the group in which the 
gastric secretion is increased, which in my 
experience forms more than half, or about 
half, of most functional diseases of the 
stomach. Up to within recent years, the 
diet question in the class of cases where 
the acid secretion is increased has been in 
a rather unsettled state. There are a 
great many physicians of repute who 
maintain that all starchy food should be 
forbidden to these patients, because it has 
been found that the symptoms in these 
cases are rather increased after the inges- 



78 LECTURES ON DIETETICS 

tion of starchy foods. The physicians 
who represent that idea have gone so far 
as to designate this class of cases as 
"starchy dyspepsia,' ' or "amylaceous 
dyspepsia,'' indicating that they ascribe 
so much importance to this particular 
thing that they found it worthy to name it 
in this way — and have arranged the diet ac- 
cordingly. According to these physicians, 
the diet for hyperchlorhydria consists in 
allowing meats and fats, taking away en- 
tirely the carbohydrates. The Salisbury 
regime, which I have mentioned before — 
meat, broths, and little toast — is also repre- 
sentative of that idea — the starch-free diet. 
Now while it is found that a patient with 
hyperchlorhydria when put upon, say, 
eggs, and a little meat and nothing else 
may be relieved of his symptoms — may 
lose his pain, belch less, and may be more 
comfortable — while all this is true at first, 
I do not think a real cure will take place 
if that diet is extended too long. 



CHBONIC AFFECTIONS 79 

Now, again, there are a number of 
physicians who represent the opposite 
view. Pawlow, the St. Petersburg physi- 
ologist, has made many experiments on 
animals, with the stomach arranged so 
that it can be looked into and examined, 
and has found that meat and all nitro- 
genous foods have a tendency to increase 
the flow of gastric juice, while vegetables, 
the carbohydrates, and fats have a tend- 
ency to diminish gastric secretion. This 
led the way to a second arrangement of the 
food in cases of hyperchlorhydria. These 
physicians said that if we give these pa- 
tients a diet rich in animal food, the gas- 
tric secretion is increased and the stomach 
is overstimulated. So they have started 
the opposite principle of feeding, and say 
that we should keep away all animal food 
from patients with hyperchlorhydria, and 
give them a strictly vegetable diet, with 
butter. 

Both parties show successes in their 



80 LECTURES ON DIETETICS 

treatment ; both have their failures — which, 
is quite natural, like everything else. 
Now, the question is, what shall you do. 
If you read the books, one will forbid all 
starchy food to these persons; almost all 
vegetables too. The other will teach just 
the opposite for the same class of cases. 
My answer to this is that neither of them 
is altogether right; for, as I told you a 
week or two ago, any diet that is arranged 
for a long period of time must contain 
all the three groups of nourishment we 
need — proteins, carbohydrates, and fats. 
While we can arrange a diet, a bill of fare, 
in such a manner that one group should 
predominate and the others be lessened, 
we cannot exclude any one of these three 
cardinal nutritious groups from any diet. 
That is a cardinal point. We must give a 
patient all these three things; but where 
there is too much secretion a starchy food 
is not so well used up, and you can give 
that patient less starchy food, and more 



CHRONIC AFFECTIONS 81 

fat and albuminates. So, in actual prac- 
tice, in these cases of hyperchlorhydria, I 
give them meat in a large amount and 
fats, and diminish the starchy food. I tell 
them that they should not eat too many 
potatoes, put no restriction on bread — for 
that is such an important article of food, 
and if some patients do not eat bread they 
cannot eat anything — and give them all 
plenty of butter. 

The reason why starch can be given to 
these patients is, first, that even if it does 
not change so quickly (the acid gastric 
secretion when reaching a certain height, 
checks the ptyalin action of the saliva, in 
the stomach), the pancreatic juice contains 
a very active ferment for the conversion 
of starch into sugar and ferments for the 
conversion of fats and albuminates ; and if 
the starch digestion is inhibited in the 
stomach it will be finished further on in 
the digestive tract. Another reason is that 
if the acidity is so great as to prevent the 



82 LECTUBES ON DIETETICS 

change of starch into sugar, we can give 
these patients alkalies to diminish the 
acidity, and that is better than to take 
away the starch; it is better to give a 
remedy than to take away the food. 

So the diet in these cases of hyperchlor- 
hydria should be a liberal one, but we must 
take away all highly spiced substances, and 
do not give them too much of the tougher 
meats, such as beef, pork, venison, but a 
liberal diet of chicken, lamb chops, or the 
tender meats, and plenty of milk, butter 
and eggs, bread and cereals, but restrict 
potatoes and other starchy substances. 

We will now consider those cases where 
there is continuous hypersecretion, the 
group in which the stomach continues to 
secrete juice even if there is no food pres- 
ent. Usually we find this condition in ul- 
cers of the pylorus; rarely, in cases of 
neurotic disturbances, either due to or- 
ganic nervous diseases, central lesions, or 
sometimes merely functional in character. 



CHEONIC AFFECTIONS 83 

What will yon do in this group? Here 
freqnent eating is of great importance. 
Try to make nse of the gastric juice which 
is given by the stomach anyway. It irri- 
tates the mncons membrane and makes the 
patient uncomfortable — but if yon put in 
some food, and especially albuminates 
which have a tendency to enter into com- 
bination with the acid — the acidity in the 
stomach is diminished and that gives them 
relief. These patients tell you that they 
have pain three hours after eating. If 
they eat, the pain is better. The acidity 
is reduced by the ingestion of food. The 
water and the albuminates in the food bind 
the acid, so that it is not only diminished 
(diluted) but some is taken away (partly 
neutralized). Some of these patients wake 
up early in the morning. The acidity is 
too great for the stomach. If they put in 
food — eat breakfast, they feel all right. 
So frequent eating is a cardinal point in 
the treatment of these cases. 



84 LECTURES ON DIETETICS 

Fats have a tendency to inhibit gastric 
secretion, and are to be recommended in 
all these classes of hyperchlorhydria, and 
continnons hypersecretion. 

Now, we will take np the cases in which 
the gastric secretion is normal. The symp- 
toms may be of a high character. The 
patient complains of all kinds of things — 
pain, eructations, loss of appetite, etc. 
This is the group designated as nervous 
dyspepsia. The symptoms are distress- 
ing, but still we find nothing radically 
wrong. We cannot find any deviation 
from the normal, and still the patient com- 
plains, and so we ascribe the condition to 
some nervous phenomena which we do not 
exactly understand. These cases have to 
be treated differently. They can eat any- 
thing, and should be made to eat every- 
thing; they should be given a liberal diet; 
no restrictions at all in these cases. Very 
often these patients with nervous dyspepsia 
eat lightly, and if kept away from food they 



CHRONIC AFFECTIONS 85 

would never get well; but if you change 
their habits of eating, the change should 
not be made too abruptly. If patients 
have been on a strict diet for a long time, 
you cannot bring on a change in a day. A 
patient who has been living on milk and 
crackers for two years if put at the table 
and given a good meal — even if the stom- 
ach is good — will have trouble. The 
stomach is not used to it. You should 
take a few days, or even a week, and grad- 
ually change the diet, until the patient is 
put in such a condition that he eats every- 
thing. All of these cases of nervous dys- 
pepsia should eat everything, but make the 
change to the regular way of living slowly. 

Now, we come to the third group, in 
which just the reverse of the first group 
exists ; the gastric secretion is diminished — 
and ultimately we will take the group in 
which there is no gastric juice at all. 

In chronic gastric catarrh there is a 
diminution of the acidity, and in func- 



86 LECTURES ON DIETETICS 

tional nervous disorders, disorders of a 
depressed character, the stomach works 
poorly and the acidity is diminished. In 
all these cases the vegetable foods should 
predominate, and not much meat should 
be given. Meat should be restricted, and 
fats as such should not be given in large 
quantities, for they have a tendency to in- 
hibit secretion. Meat, on the other hand, 
has a tendency to increase secretion, but 
if too much is given it creates a disturb- 
ance^ — so we give enough meat, and less 
fat. 

Now, all these questions have been 
worked out by the physiologists, but we 
cannot take their findings right away into 
the clinic and say, "We go according to 
them." It is only if they have been 
proven to do good in practice that we can 
adopt them. Until then, we cannot go by 
them alone. In Germany especially, many 
clinicians act too much on these physiologi- 
cal experiments. They at once give a diet 



CHRONIC AFFECTIONS 87 

according to these rules. But that is not 
the best way. It is best to go by what we 
find to be of clinical value, and to leave the 
theories, as such, alone. If we find some- 
thing practical, and this corresponds to a 
certain physiological theory, so much the 
better. 

Now we come to the class of cases in 
which there is no gastric secretion, achylia 
gastrica. That is a large group. These 
patients have no organic disease, and yet 
have distressing symptoms. It is the re- 
sult of something else. The condition is 
easily managed, and the dietetic treatment 
here plays a great part. The food is 
changed very little in the stomach in these 
cases, for there is no gastric juice. Not 
only the albuminates but also the starch 
and fats are unchanged. Starch as such 
would change in such a stomach, but the 
starch is usually enclosed in a membrane 
of plant albumin, and this little membrane 
or coating which surrounds the starch is 



88 LECTURES ON DIETETICS 

usually opened by the gastric juice; but 
in cases of achylia there is no gastric juice, 
and the ptyalin cannot reach the starch 
and enter it; and that is the reason why 
starch cannot change in cases of achylia. 
If you want the starch changed, you must 
see that the particles of food are entirely 
broken up, pulverized almost; that has a 
tendency to open up the little cells in such 
a way as to reach the secretion. 

Another reason why these patients 
should have their food prepared in a 
finely divided form is again the circum- 
stance that there is nothing in the stom- 
ach to help the dissolution of these parti- 
cles. Normally, the gastric juice dissolves 
the connective tissue surrounding the meat 
and prepares it for further digestion in 
the intestine. In a case of achylia gas- 
trica the meat which is swallowed remains 
unchanged until it reaches the duodenum. 

The connective tissue surrounding the 
meat fibers does not disappear, and it 



CHRONIC AFFECTIONS 89 

reaches the duodenum in the same shape 
in which it was ingested. It looks as 
if it had been masticated and spit out. 
Some of you have seen me take out such 
stomach contents exactly as if it had 
been chewed a little and then brought out. 
So the mechanical division of the food is 
important in these patients with achylia. 
If the food comes into the duodenum un- 
changed it creates symptoms — pain, etc., 
and the patients surfer from catarrh of 
the bowels, frequently causing constipa- 
tion alternating with diarrhea. Not only 
in the stomach but also in the intestines 
the food continues to be an irritant. 

So the foods in these cases should be 
finely divided mechanically. Accordingly 
we give these patients cereals in fine form, 
pea soup, lentil soup, mashed potatoes, 
raw and soft boiled eggs. If you give 
them hard boiled eggs, they will remain in 
the stomach, but raw eggs which are semi- 
liquid will slip through. We give these 



90 LECTURES ON DIETETICS 

patients very little meat, for the reasons 
which I have already mentioned. I have 
found very often that by such a strict diet 
of liquid and semi-solid food — they must 
be told to masticate their food well — that 
they can get along very well. The diet 
brings on a great improvement. 

But shall we let these patients continue 
on such a diet indefinitely! No. The 
principle to which I have already referred 
is important not only in the other groups 
but here also — that a diet deviating much 
from the normal should not be kept up in- 
definitely. Our tendency should be to 
strengthen the digestive tract and harden 
it, and bring it to such a state that it can 
manage normal food. No matter whether 
the constitutional condition is changed or 
not — we may not be able to remove it, but 
if we can change the patient's manner of 
living so that he can live like other people, 
— we have attained what we want. "We 
want to take the patient away from inva- 



CHRONIC AFFECTIONS 91 

lidism, and from anything that tends to 
keep him in that condition. 

Here too, in achylia gastrica, while at 
first we are strict in having these patients 
live on fine foods, step by step we intro- 
duce other things, and arrange so that in 
time they can digest ordinary diet. It 
takes time — a month, perhaps two or three 
months, — but that should be the aim. I 
usually find that these patients with 
achylia can live twenty, thirty, or forty 
years, and even become normal individ- 
uals. If you can bring them to a state 
where they can enjoy a normal meal, they 
are practically well. The intestine is 
strengthened in such a way that it learns 
to do the work which the stomach ought 
to do. That can be clone by a gradual 
change of diet, increasing it step by step. 
This principle must extend to all chronic 
conditions. 

Another point of great importance. 
Many of these dyspeptic individuals — no 



92 LECTURES ON DIETETICS 

matter what the character of their diges- 
tive disease — have been forbidden a great 
deal, and have lived with so little nourish- 
ment that they are in a condition of sub- 
nutrition. They are run down, and can- 
not do anything; they lead lives of in- 
validism, lie on a lounge, etc., and many 
of them gradually die of starvation. The 
nerves are not nourished; all the organ- 
ism is in a state of inanition, like a busi- 
ness in which there is too little money. 
Such a business cannot go on well. So 
with the organism. If the body has not 
enough food, it takes a little of its own fat 
and muscle, and that will not do. That is 
what these patients really represent. 
They are dizzy and have no appetite, and 
are weak — all symptoms of inanition. If 
we treat these patients by giving them a 
diet on which they have just enough to 
lead their existence, they will never get 
well, for they remain in that weakened 
condition. But if we can feed them up — 



CHRONIC AFFECTIONS 93 

increase their diet, give them more food 
than they need, build them up — we can get 
them well. The question in all these cases 
is — can you do it? My answer would be 
that in nine cases out of ten, or perhaps 
still more, you can do it, provided there is 
no organic lesion present — no cancer, no 
obstruction; simply a lack of nutrition, 
some functional disturbance. From my 
experience, I would say that in more than 
nine cases out of ten you can succeed in 
changing such an individual and building 
him up. 

The question is : How to do it J ? I an- 
swer: First change the diet, and change 
it gradually, as I said before. You can- 
not do it in a day. The intention is to 
have the diet similar to what the patient 
has been having, only we make it more 
nutritious gradually. Suppose you have 
succeeded in changing it and the patient 
now takes three meals a day, and you want 
him to gain flesh. This applies not only 



94 LECTURES ON DIETETICS 

to diseased individuals, but to any one. 
We have a number of thin persons here, 
some of whom might like to gain a little 
flesh. Some one may want to gain, but he 
says, "my family is thin, we are all thin; 
I cannot do anything. " That is what 
people usually say: "We are all thin; 
that is the way we grew up. ' ' 

But such people can be made stouter. 
We can make them gain if they carry out 
what is needed. Such a person takes for 
breakfast, say a cup of coffee, an egg, and 
a roll. If we want him to gain, we must 
try to make this bill of fare more nutritive. 
Instead of coffee, we say, take two parts 
of milk and one part of coffee; then he 
has more milk. Then we tell him to take 
a great deal of butter on his bread, and to 
take two eggs instead of one, and butter 
with them. Then for lunch, do the same 
way. Make the foods which he has been 
taking more nutritious, take more cream, 
more sugar. If the patient has been just 



CHRONIC AFFECTIONS 95 

maintaining his weight all the time on his 
former diet, make the drinks more nu- 
tritious. In a week or two he will report 
that he has gained a pound ; if he keeps it 
up, he will gain more — if he keeps up the 
same amount of work. Now he begins to 
take more milk and more butter. "What 
he does not need to maintain his balance 
goes to make more flesh. If you want 
some one to gain and he has been walk- 
ing three miles a day, and it is essential 
that he should gain weight, have him take 
between meals a glass of milk and bread 
and butter. At first he will tell you that 
his appetite is not so good for the next 
meal, but he will soon get used to it. That 
is practically the way I proceed with these 
patients where it is necessary to build 
them up. Have them take their regular 
meals, and add two small meals in between. 
I lay much stress on the amount of butter. 
Tell them to eat a quarter of a pound of 
butter a day. A quarter of a pound of 



96 LECTURES ON DIETETICS 

butter contains almost a thousand heat 
units. If he eats a quarter of a pound of 
butter a day, he has a thousand heat units 
added, which he does not need for living, 
and it goes into fat. Butter is easily taken 
up — you can put it in oatmeal, eggs, on 
bread, etc. The patient enjoys it, and eats 
more. So butter is a very important arti- 
cle of food, in those cases, where it is es- 
sential to increase the body weight, and 
it is essential in many instances. 

If a man is all right, leads an active life, 
that is all right. But if he is very thin, 
barely covers his expenses, if he gets sick 
he has not much to draw upon, so it is well 
to have a reserve fund of flesh to draw 
upon. 

The same principle can be turned 
around. Normally, we should be just 
right — not too stout, not too thin. There 
should be harmony and symmetry, and if 
a person looks just right, you can judge 
by the appearance that he is all right. 



CHKONIC AFFECTIONS 97 

But if you grow clumsy and can hardly 
move about, that is not well. Can you 
reduce the weight of such persons by diet? 
Yes. But here again is a point of great 
importance, that is, exercise. If you have 
a stout fellow taking food that just keeps 
him in his balance — he does not gain and 
he does not lose, and you want him to lose 
and still you do not want him to reduce 
his bill of fare too much, for if you make 
him take too little he may have some heart 
complications — increase his exercise. If 
he is used to walking two miles a day, make 
him walk three or four, and then five, or 
make him climb a mountain, and with the 
same food he begins to lose gradually. 
That is the best way of reducing flesh ; but 
if you see that he is eating too much, eats 
enough for three people, then reduce his 
food. Instead of taking milk, give him 
coffee and tea for breakfast, and take away 
the butter; and if he eats between meals, 
tell him to have three meals instead of 



98 LECTURES ON DIETETICS 

five. Treat him the opposite way from 
the management of increasing weight and 
yon can succeed in reducing flesh. 

People can increase or diminish bodily 
weight at will, provided these instructions 
are carried out. It is far more difficult, 
however, to make a stout man thin than 
to make a thin man stout, because what 
you want is not to the fancy of the corpu- 
lent man, though it is all right for the thin 
man, for he soon leams to enjoy his food. 
But the stout man does not want to give 
up his butter, and keeps on eating a little 
more than he needs. Otherwise it would 
be as easy to reduce as to fatten an indi- 
vidual. You can succeed even here in 
nine cases out of ten, provided all the in- 
structions are rigidly carried out. 



LECTUBE V 

THE DIETETIC TREATMENT OF CHRONIC 
DIARRHOEAS * 

I have selected the dietetic treatment of 
chronic diarrhoea because this subject of 
diet is an important one in all diseases, 
and particularly so in affections of the di- 
gestive tract, as there we have to deal with 
an apparatus which is arranged to sustain 
the organism. 

In order to discuss this subject of dietetic 
management of chronic diarrhoea, it would 
be well to divide its forms into different 
classes. 1, Diarrhoea due to chronic in- 
testinal obstruction; 2, nervous diarrhoea; 
and 3, chronic diarrhoea, due to catarrh of 
the small intestine principally, sometimes 
also accompanied by a catarrhal condition 

* New York Med. Journal, Feb. 10, 1906. 
99 



100 LECTURES ON DIETETICS 

of the colon. Most forms of chronic di- 
arrhoea principally involve the small intes- 
tine; and this group can again be sub- 
divided into 1, primary catarrh ; 2, catarrh 
depending upon abnormalities of gastric 
secretion; and 3, catarrh accompanying 
ulceration. 

In the treatment of all these types of 
diarrhoea it is primarily important that 
we should make use of those foods which 
are nonirritating and which leave little 
residue. They must not irritate the bowel 
mechanically nor chemically, nor must they 
be very cold when ingested. 

The special treatment of each class will 
call for a difference in the dietetic regime. 
In chronic intestinal obstruction, so long 
as the patient is not operated on and the 
obstruction exists, the first principle will 
be that the diet should be a liquid one. 
This liquid diet will have to be maintained 
because solid food will not pass through 
the narrowed canal. It will be vomited 



CHRONIC DIARRHCEAS 101 

and will aggravate the symptoms. We 
may give milk, raw eggs, and different 
kinds of broths and meat juices, but this 
will be all which we may allow. Varia- 
tions to improve the taste, and bring more 
variety into the menu may be introduced, 
but in the main the foods will remain the 
same. 

A reverse course must be adopted in that 
form of diarrhoea which is of nervous ori- 
gin. In this disorder, as far as we know, 
there is really no anatomical lesion to be 
found. It is simply a functional disease, 
and the chief feature of this type of diar- 
rhoea is that nervous phenomena accom- 
pany it and also bring it on. This means 
that in addition to a diarrhoea the patient 
also manifests other nervous symptoms. 
He perhaps cannot sleep well, his appetite 
is capricious, and then the diarrhoea itself 
also manifests a character which shows its 
nervous origin. The patient will have a 
movement of the bowels principally after 



102 LECTURES ON DIETETICS 

meals, or when he will have to meet a 
very important engagement; a professor 
before giving a lecture will have to excuse 
himself and leave the room, indicating 
that the state of mind has something to do 
with the movement of the bowels. 

In these cases the whole management 
should be different from those which are 
due to anatomical lesions in the intestines. 
The diet, too, must therefore be arranged 
accordingly. It will not have to be such a 
rigorous one. We will have to make the 
patient eat almost everything. Even 
those foods which leave a residue do not 
play much part. I remember I had to 
treat a physician in this city who had this 
kind of a diarrhoea. He had to excuse 
himself after finishing each meal. The 
main treatment is that the patient should 
try and suppress these movements, i. e., 
not to run to the toilet as often as he feels 
inclined, and besides other means, nerve 
sedatives. The diet should not be re- 



CHRONIC DIAEEHCEAS 103 

stricted; food of a laxative nature, how- 
ever, should be avoided; otherwise these 
patients can eat everything. 

Now we come to that class of diarrhoea 
which is due to disturbances of the stom- 
ach. This is a group which has been recog- 
nized only in the last seventeen years. We 
have learned to know that there are forms 
of diarrhoea in which the small and large 
intestines are not very much involved, 
but in which we find abnormal conditions 
in the stomach itself, and if we try to 
arrange a treatment suitable to the de- 
rangement of the stomach, the diarrhoea 
as such can be neglected and still will be 
cured. 

There are two lesions in the stomach, 
functional disturbances, which form the 
greater part of this class of diarrhoeas. 
One is the form which is called achylia 
gastrica, in which there is no gastric juice 
whereby the stomach does not digest al- 
buminoid foods. Here the food enters the 



104 LECTURES ON DIETETICS 

intestine practically unchanged, and thus 
irritates the bowel, causing the diarrhoea, 
at least in some cases. Achylia gastrica 
is not always accompanied by diarrhoea. 
I think, on the contrary, that more than 
one half of the cases are accompanied with 
extreme constipation, but about one third 
of these cases of achylia gastrica are trou- 
bled with obstinate diarrhoea, and this diar- 
rhoea is probably due to mechanical irrita- 
tion within the small intestine. 

Diarrhoea may also be brought on by 
just the reverse condition, i. e., one in 
which there is too much secretion and too 
much acidity in the stomach. Here it is 
not the mechanical irritation but most 
likely the acid itself which exerts an irri- 
tating stimulus on the intestinal mucosa, 
which leads to the diarrhoea. This class, 
however, is a small one. Most patients 
who suffer from hyperchlorhydria suffer 
from constipation, and only a small frac- 
tion suffer from diarrhoea, but we must re- 



CHRONIC DIARRHCEAS 105 

member that such a group exists, as some- 
times they may be cured by alkalies. 

In these two groups, in which the diar- 
rhoea is dependent upon a gastric anomaly, 
the entire treatment, medicinal and die- 
tetic, will have to be arranged to suit the 
stomach. In the patients with achylia 
gastrica we find it expedient empirically, 
not merely theoretically, to exclude pro- 
teids from the diet. Such patients do 
much better on a diet which contains little 
meat or no meat at all. They should live 
on a vegetarian diet. A vegetable diet is 
inclined, as a rule, to predispose to diar- 
rhoea, but in this group of cases it is just 
the remedy. If one keeps a patient on 
gruels and perhaps on nicely divided arti- 
cles of food, milk, kumyss, later on bread 
and butter and omits meat entirely for a 
time, we will find that in a few weeks he will 
not suffer so much from the diarrhoea. I 
think this to be the experience of almost all 
the physicians who handle these cases. Ac- 



106 LECTURES ON DIETETICS 

cording to my experience, however, it is 
not necessary to institute a rigorous diet 
nor to avoid meats altogether for a very 
long period. If we give the patient finely 
divided foods for a few weeks, at first 
liquid, then semi-liquid foods, we can then 
after a time begin to allow foods a lit- 
tle coarser, bread, vermicelli, barley, rice, 
and later on meat. We will find that the 
bowels will gradually get accustomed to 
these foods, even if they do not get into 
the intestine in so finely divided a state. 
These patients should masticate their food 
carefully. This is more important here 
than in any other class of stomach de- 
rangements. These patients do well on 
starchy foods. 

Diarrhoea, if due to a condition of hyper- 
chlorhydria, will have to be managed quite 
differently. Here meats, a richly albu- 
minous diet, will play an important part. 
These patients will do well on plenty of 
meat and eggs, and very little starchy food 



CHRONIC DIARRHOEAS 107 

— just the opposite of those suffering from 
achylia — and also an alkali. 

In the first group, achylia gastrica, it is 
not essential to administer hydrochloric 
acid, but in the second group, hyperchlor- 
hydria, we will have to give alkalies. 

We shall proceed now to the larger group 
of chronic diarrhoea, due to abnormal con- 
ditions in the small intestine. This is the 
more difficult group to handle outside of 
the group due to intestinal obstruction 
(which we can only cure by an operation; 
otherwise we have to keep to liquid diet). 
This group, in which there is a chronic 
catarrh of the small intestine, comprises 
perhaps more than half the cases suffering 
from diarrhoea. Here diet plays a very 
important part, and we will have to dis- 
cuss a little more minutely how to handle 
them and what we should do. 

There is no unaminity of opinion among 
physicians nowadays as to the kind of diet 
to be given to such patients. Some say that 



108 LECTURES ON DIETETICS 

these patients will do well on an exclu- 
sively meat diet ; others again will say that 
patients get well on an exclusive milk diet. 
Others again say that milk is the worst 
thing. Among the latter is Professor 
Rosenheim, who recently wrote an article 
on this group of diarrhoeas. He says that 
he always failed with milk in such cases, 
because the milk sugar easily breaks down 
into lactic acid, which upsets the patient. 
He therefore excludes milk from the diet 
of these patients. He even goes so far as 
saying that the admixture of milk to cacao 
or to soup, and a little cream will also upset 
the patient. 

So far as I am concerned I must say that 
I am not so much afraid of milk and I am 
rather of the opinion that while we should 
exclude all fruits, salads, highly spiced 
dishes, all irritating substances and cold 
beverages (all things which have a tend- 
ency to increase peristalsis should be care- 
fully avoided), we should still try to give 



CHRONIC DIARRHCEAS 109 

a sufficient quantity of nourishment to 
these patients even if their actual condi- 
tion of diarrhoea should apparently grow 
worse through the diet. I am of the 
opinion that if we are timid and give these 
patients very little food, they will, notwith- 
standing the improvement of their diar- 
rhoea, perhaps having only two or three 
movements a day, soon surfer in their nu- 
trition and the body weight will decrease. 
The great danger is that if such a condition 
of subnutrition is kept up, after a while we 
cannot cure such patients at all. This is 
the case with a great many of these pa- 
tients. 

In reality it is advisable to give rest to 
an organ which is diseased and it will then 
recuperate and do well later on and do 
more work. You may, in severe cases of 
diarrhoea, try such treatment. We may 
give the patient very little nourishment, 
perhaps egg albumen water, but if so one 
should always bear in mind not to restrict 



110 LECTURES ON DIETETICS 

the patient to this diet more than a week 
or ten days. After this period we must 
reestablish the amount of nourishment, 
and put the patient on a regime which will 
build him up. It is important to consider 
that even though the patient feels im- 
proved and the chronic diarrhoea gets bet- 
ter on the restricted diet, he may be getting 
too little nutrition and a state of inanition 
results. The organs are weakened and 
the disease instead of growing better be- 
comes aggravated. In this weakened state 
the organism is not able to recuperate. 
For this reason I say that in these cases 
of chronic diarrhoeas, after having tried 
a very short period of time with little nu- 
trition or no nutrition at all, we must give 
them plenty of food, plenty of eggs — eggs 
are indeed very good in these cases — six 
or eight eggs a day I generally give. We 
give them plenty of gruels and barley. 
You may try decoctions of barley, oatmeal 
and rice, and later on give them porridges, 



CHRONIC DIARRHCEAS 111 

and then bread and butter, and then meats. 
I do not exclude meats. I do not give them 
any fruits, salads or any cold drinks or 
anything of an irritating nature. Nour- 
ish them well. 

What will you do if the diarrhoea is kept 
up? How will you manage that? Here 
certainly we must take recourse to some 
medicinal treatment. We may give them 
a tannic acid preparation; we may admin- 
ister an opiate. It is much better to make 
the patients eat and keep them on some 
remedy, so that they are able to keep up 
with feeding and check the diarrhoea a 
little, than not to allow them to eat and not 
to take medicine. 

I have found by experience that a great 
many patients soon begin to gain in weight, 
in fact in most of these cases you can 
achieve a gain in weight if you give them 
sufficient nourishment, more than enough to 
keep the body in balance. They will add 
flesh too, and as soon as they are stronger 



112 LECTURES ON DIETETICS 

they are able to fight the disease and do not 
require so much medicine. I have seen such 
cases. I particularly remember a patient 
who lost fifty to sixty pounds from chronic 
diarrhoea. She did not eat anything that 
was forbidden her, and she thought that 
milk increased the diarrhcea, also bread, 
and she did not wish to eat. Ultimately she 
took nothing. Her condition was so bad 
that she was almost a skeleton, but after 
I allowed her to eat and gave her in addi- 
tion some slight remedy, after a few weeks 
she picked up and in two or three months 
recovered. 

It is thus with a great many other pa- 
tients, and I think it is very essential to 
bear in mind how important a part nutri- 
tion plays in prolonging life and curing 
disease. 



LECTURE VI 

THE DIETETIC TKEATMENT OF DIABETES 
MELLITUS * 

In no disease does diet form a more im- 
portant part of the treatment than in dia- 
betes mellitus. As is well known, the na- 
ture of the disease consists in the fact that 
the organism is unable either entirely or 
nearly so to utilize the carbohydrate foods. 
We thus have to deal with a genuine 
anomaly of metabolism, and the main 
points of treatment will consist of a ra- 
tional and appropriate diet so long as 
there is no specific remedy for this disease. 
As it is possible to live on meat and fat 
alone without carbohydrates, it was nat- 
ural to exclude this latter group of food- 
stuff from the diabetic diet. This was, in- 

* Journal American Medical Association, Dec. 29, 1906. 
113 



114 LECTURES ON DIETETICS 

deed, done by the earliest observers who 
had knowledge of the nature of diabetes 
(Rollo, 1796), and this diet was adhered 
to with slight modifications nntil the pres- 
ent time. 

The following disadvantages are at- 
tached to a purely animal diet: It offers 
too little variety and departs too much 
from the usual mode of life, and in this 
way will soon pall on the appetite. At the 
same time it is poor in inorganic salts, thus 
predisposing to a surcharge of the organ- 
ism with acids (acidosis) and subsequent 
comatose conditions. 

An absolute meat and fat diet can be 
borne for only a short period. Such a diet 
would be about as follows: 

STRICT DIET. 

8 a.m.: Two eggs, butter, tea ; 11 a. m. : Ham, 
wine ; 1 p. m. ; Beef tea, 200 grams of meat or 
fish, one egg, lettuce or spinach ; 4 p.m.: Coffee, 
two eggs and butter; 7 p.m.: Three eggs fried 
in lard, or fish with eggs or cold roast. 



DIABETES MELLITUS 115 

A trace of sugar is contained even in 
this diet, but it hardly amounts to over 1 
per cent. By the addition of some milk 
and cream this diet may be made a little 
more agreeable, although the quantity of 
sugar is greater. 

Such a diet list may be put together 
about as follows: 

INTERMEDIATE DIET. 

Breakfast : 200 grams of milk with 50 grams 
of cream, two eggs, butter and 100 grams of 
roast. 

Dinner: 200 grams of meat or fish with 
asparagus or peas, salads. 

4 p. m. : 200 grams of milk with 50 grams of 
cream. 

Supper: Four scrambled eggs with 120 
.grams of ham. 

C. von Nborden* determines first how 
much carbohydrate a patient can assimi- 
late and allows about half of this. Such 

* C. von Noorden : "Ueber Hafercuren bei schwerem 
Diabetes mellitus," Berl. klin. Wochschr., 1903, No. 36, 
p. 817. 



116 LECTURES ON DIETETICS 

a procedure appears very rational, but 
can be conducted only in special clinics 
and not in general practice. It is best to 
arrange the diet according to customary 
principles, varying it slightly to fit the in- 
dividual requirements of the patient. 
Whether or not a diet agrees with the pa- 
tient can best be determined by noting the 
diminution of the quantity of sugar, as 
well as the total daily quantity of urine, 
and secondly and mainly by the patient 
feeling better and stronger. 

According to the experience of most 
clinicians, it is best to permit diabetics a 
certain, although limited, amount of car- 
bohydrates. 

Seegen's * diet list for diabetics is prob- 
ably the best known and, therefore, I will 
quote it in full: 

*J. Seegen: "Der Diabetes mellitus," Berlin, 1895; 
see also Friedenwald and Ruhrah: "Diet in Health and 
Disease," 1905, pp. 470-471. 



DIABETES MELLITUS 117 

SOLIDS. 

Allowed in Any Quantity. — Meat of every 
kind, smoked meat, ham, tongue, fish of every 
kind, oysters, mussels, crabs, lobsters, meat 
jellies, aspic, eggs, caviar, cream butter, cheese 
and bacon. Of vegetables: Spinach, lettuce, 
endive, Brussels sprouts, pickles, fresh aspara- 
gus, watercress, sorrell, artichokes, mushrooms, 
nuts. 

Allowed in Moderate Quantity. — Cauliflower, 
carrots, turnips, cabbage, green beans, berries, 
such as strawberries, raspberries, currants, also 
oranges and almonds. 

Forbidden Absolutely. — All foods made from 
flour or meal; bread is allowed in moderate 
quantities, according to the physician's orders; 
sweet potatoes, rice, tapioca, arrowroot, sago, 
grits, vegetables, green peas, cabbage, sweet 
fruits, especially grapes, cherries, peaches, 
apricots, plums and dried fruit of every sort. 

BEVERAGES. 

Allowed in Any Quantity. — Water, soda water, 
tea and coffee. Of wines: Bordeaux, Rhine 
wine, Moselle, Austrian and Hungarian table 
wines — in a word, all wines that are not sweet 



118 LECTURES ON DIETETICS 

and that do not contain more than the average 
amount of alcohol. 

Allowed in Moderate Quantity. — Milk, bitter 
beer, unsweetened almond milt, lemonade with- 
out sugar. 

Forbidden. — Champagne, sweet beer, cider, 
fruit wine, sweet lemonade, liqueurs, fruit juices, 
water ices, sorbets, cocoa and chocolate. 

In general, I use about the same diet as 
Seegen and give the following: 

Calories. 

Breakfast : Three eggs 240 

Half a roll (20 grams) 50 

Butter (30 grams) 251 

Coffee (150 grams), milk (100 

grams), cream (50 grams) . . 203 
Dinner : A plate of soup (200 grams), with 

egg 85 

Meat (200 grams) 200 

Half a roll and butter (15 grams) 175 
Asparagus with butter sauce 

(salad) 30 

Supper : Oysters or fish (100 grams) 100 

Three scrambled eggs with butter 

(15 grams) 365 



DIABETES MELLITUS 119 

Half a roll with butter (15 grams) 175 

Westphalian ham (50 grams) . . . 200 

Apples, tea and cream (50 grams) 138 



2,212 



Various diet cures have proved of value 
in diabetes. Of these the best known are 
the "milk cure" of Wintered tz,* the "po- 
tato cure" of Mosse, and the "oatmeal 
cure" of Von Noorden.f 

Whereas Mosse 's potato cure has not 
proved of much value, the other two cures 
are useful in suitable cases. They should 
not be extended over too long a time be- 
cause a too limited diet is harmful if con- 
tinued too long. Winternitz's milk cure 
consists in the patient taking milk exclu- 
sively (about four quarts daily). 

Von Noorden recommends his oatmeal 
cure, especially in grave cases of diabetes. 

* Winternitz und Strasser : "Strenge Milchkuren bei 
Diabetes mellitus," Centbl. f. innere Med., 1899, No. 45. 

f C. von Xoorden : "Ueber Haf ercuren bei scbwerem 
Diabetes mellitus," Berl. klin. Wochschr., 1903, Xo. 36. 
p. 817. 



120 LECTURES ON DIETETICS 

He uses either Knorr's oatmeal or Hohen- 
lohe's oatmeal flakes. This substance is 
boiled in water for a long time with a little 
salt; while boiling butter and a vegetable 
albuminoid or, after cooling, the beaten 
white of eggs are added. Roborant may 
be employed for this purpose with good ad- 
vantage. The daily quantity is 250 grams 
of oatmeal, 100 grams of albumin and 300 
grams of butter. The soup prepared in 
this manner is given every two hours. 
Cognac or wine or black coffee may also be 
permitted. 

No matter what form of diet is insti- 
tuted, it is always essential to see that the 
quantity of food is sufficient. In this re- 
spect fat (butter, cream, oil, lard) is of 
more importance here than in other condi- 
tions. Alcohol, taken moderately in the 
shape of whisky, cognac or wine, is also 
of value. The body receives in the first 
place more fuel (as 50 grams of alcohol, 
which may be put down as the daily quan • 



DIABETES MELLITUS 121 

tity, contain about 350 calories), and sec- 
ondly because the patient, with the addi- 
tion of wine, can take more of the greasy 
food than without it. 

STOMACH COMPLICATIONS. 

After thus having touched on the fun- 
damental principles of diet in diabetes mel- 
litus, I would like to add a few words about 
it in those cases of diabetes which are 
complicated with affections of the stomach. 
Two groups of functional disturbances of 
the stomach are found most frequently in 
diabetes, hyperchlorhydria and achylia. 

If hyperchlorhydria complicates dia- 
betes the treatment is easy, as the diet is 
the same in both (principally fat and albu- 
min). Even the medicinal treatment of 
hyperchlorhydria (alkalies, sedatives) in- 
fluences also the diabetes favorably. 

It is different in achylia gastrica com- 
plicating diabetes. As is well known, 
meat is not well borne in achylia gastrica, 



122 LECTURES ON DIETETICS 

whereas a vegetarian diet (plenty of car- 
bohydrate) usually agrees best with these 
patients. We are thus confronted by a 
dilemma. The diabetes requires a pre- 
ponderance of animal, the achylia a pre- 
ponderance of vegetable food. We must 
find a way to select the food so that while 
it is rich in protein and fat it still con- 
tains little meat. 

In these cases a trial of the von Noorden 
oatmeal cure would be appropriate. 

In numerous cases of such a combina- 
tion of achylia and diabetes I have used 
the following diet list with advantage: 

Calories. 

Breakfast : Three soft boiled eggs 240 

One roll (40 grains) 100 

Butter (30 grams) 251 

Coffee (200 grams) and cream 

(50 grams) 138 

Dinner: Beef tea (200 grams), with meat 

powder (30 grams) 118 

Three scrambled eggs 240 



DIABETES MELLITUS 123 

Half a roll 50 

Butter (30 grams) 251 

Spinach or asparagus (50 grams) 82 

Supper : Two eggs beaten with 150 grams 

of milk and 50 grams of cream 394 

Mashed Potato (50 grams) 63 

Crackers (10 grams) 24 

Cream cheese (20 grams) 79 

Butter (30 grams) 251 

9 :30 p. M. : 300 grams of Kumyss with 

Almonds and nuts 100 



2,381 



It is understood, of course, that this diet 
must be somewhat varied. I often use pea 
soups, although they contain a considerable 
amount of carbohydrates. 

After the patient has lived on this diet 
for about one week, it is better to add for 
dinner some meat (chicken, calf's brain, 
sweetbread or chopped meat). 

The main point in the treatment of these 
patients lies in the fact that they have to 
take more carbohydrates than usual and 



124 LECTURES ON DIETETICS 

that they do better under this mode of 
treatment. 

The nrine naturally must also serve here 
as an indicator to determine whether or 
not the amount of carbohydrate is harm- 
ful. 

Another class of digestive disturbances 
occurring in diabetics is that of catarrh 
of the stomach or bowel. We usually 
have to deal with acute affections of the 
stomach and bowel, or of both organs, pro- 
duced by overfeeding with too greasy or 
too heavy food. 

In these cases the dietetic treatment 
must be directed especially against the 
acute affections and we must leave the 
diabetes out of consideration. 

A bland meager diet is the main thing 
(beef tea, gruels, milk, possibly raw eggs 
beaten up in milk or beef tea). When the 
acute stage of the digestive disturbances 
is passed we can slowly return to the anti- 
diabetic diet. 



LECTURE VII 

DIET KEGIMES 

In my previous lectures I have given the 
principles of diet in health and disease. 
Based upon them every physician will be 
enabled to arrange a diet suitable to the 
requirement of each case. In the follow- 
ing, however, I thought it best to describe 
briefly several important standard diet 
regimes, which can be used to advantage 
for shorter or longer periods of time in 
appropriate cases but never indefinitely. 

I. SUPERALIMENTATION REGIME. 

Breakfast, 7 :30-8 a. m. : Oatmeal with but- 
ter, or farina with cream, 2 eggs, bread (1-2 
rolls) and butter, one cup of coffee (half milk) 
with sugar. 

10 :30 : One cupful of milk with one raw egg 
beaten up in it; bread and butter. 
125 



126 LECTURES ON DIETETICS 

Luncheon, 12:30-1: One cup of bouillon 
with one egg, 1-2 rolls, butter, tender meat, 
mashed or baked potato; weak tea (half milk) 
with sugar. 

3 :30 : Same as 10 :30 A. M. 

Dinner, 6:30-7: Cream soup; fish; tender 
meat, potato, peas or beans; bread and butter, 
stewed fruit ; small cup of coffee. 

9 :30 : Kumyss and crackers and butter. 

The quantity of butter to be used daily should 
be about a quarter of a pound. 

This superalimentary regime can be 
kept up for a long period of time and is 
suitable in conditions in which a building 
up of the system is required. 

II. PROTEID — FAT REGIME. 

a) 

Breakfast: One cup of tea (no sugar, no 
milk), one egg with butter, one portion of ham, 
or bacon. 

Dinner: One cup of bouillon (§vii), 200 gm. 
(gvii) meat or fish broiled, 2 eggs, hard boiled, 
lettuce, spinach or asparagus, one cup of tea. 

Supper: Fried eggs (3) and bacon, or fried 



DIET EEGIMES 127 

fish with hard boiled eggs or a portion of cold 
meat, 150 gm. (sv). 

This diet is suitable for diabetes mellitus 
and for reducing corpulency. Elderly per- 
sons and patients with heart and kidney 
lesions do not bear well this rigorous 
regime. It is then necessary to add some 
more vegetables (green peas, beans) and a 
small quantity of milk or cream to the 
above bill of fare. 

b) Banting's Begime. 

Breakfast: Meat (beef, mutton, kidneys, fish 
or ham), 120-150 gm. (§iv-v) ; one big cup of 
tea (without milk or sugar) ; zwieback or toasted 
bread (without butter), 30 gm. (§ii) . 

Dinner: Fish (excepting salmon) or meat 
(excepting pork), 150-180 gm. (gv-vi) ; vege- 
tables (excepting potato) ; toasted bread, 30 
gm. (§i) ; (red wine or Madeira, 2-3 glassfuls 
permissible; champagne or ale forbidden). 

During the afternoon: Fruit, 60-90 gm. 
(gii-iii) ; 1-2 zwieback; one cup of tea without 
milk or sugar. 



128 LECTUBES ON DIETETICS 

Supper: Meat or fish, 90-120 gm. (giii-iv) ; 
grog without sugar or 1-2 glassfuls of claret. 

Notwithstanding the apparent great 
amount of foods this bill of fare contains, 
it furnishes but 1100 calories per day. 
The Banting regime is used principally as 
an antifat diet. A great many patients, 
however, cannot stand it and frequently 
collapse after using it a few days. 

Ebstein improved the Banting regime 
and modified it as follows : 

c) Ebstein-B anting Regime. 

Breakfast: Tea, one cup, without milk or 
sugar; bread, 50 gm. (§if), plenty of butter. 

Dinner: Soup, one plate; meat, 120-180 
gm. (giv-vi), fried or boiled with rich gravy; 
beans, peas and cabbage ; (no potatoes, no beets) ; 
salad; raw or baked fruit without sugar; mild 
white wine, 1-2 glassfuls. 

In the afternoon same as at breakfast. 

Supper: One cup of tea without sugar or 
milk; one egg; fried meat or ham, smoked fish; 
bread about 30 gm. (§i) well buttered; a small 
portion of cheese, and fresh fruit. 



DIET REGIMES 129 

d) Oert el-Banting Regime. 

Breakfast: Wheaten "bread, 30 gm. (Si) ; cof- 
fee, 120 gm. (giv), with milk, 30 gm. (Si); 
sugar, 5 gm. (3i) ; 2 soft-boiled eggs (90 gm. or 

Siii). 

At 11 a. m. : Wine, bouillon, or water, 100 
gm. (giiiss) ; cold meat, 50 gm. (§if ) ; rye bread, 
20 gm. (S|). 

Dinner: Wine, 250 gm. (gviiij) ; fried beef, 
150 gm. (gv) ; salad, 50 gm. (gif ) ; pudding, 
100 gm. (giiij) ; bread, 30 gm. (gi) ; fruit, 100 
gm. (giiij). 

4 p. m. : Coffee, 120 gm. (§iv) ; milk, 30 gm. 
(Ji) ; sugar, 5 gm. (3i). 

Supper: Wine or water, 250 gm. (§viii^) ; 
caviar, 12 gm. (oiii) ; venison, 150 gm. (§v) ; 
cheese, 15 gm. (§ss) ; rye bread, 20 gm. (3v) ; 
fruit, 100 gm. (Siiii). 

III. VEGETARIAN DIET REGIME. 

a) Schroth's Dry Diet. 
Patient is allowed to eat dry well-baked 
rolls, 2-3 days old. At noon-time he takes a 
soup, made out of water, rice, farina or broken 
up rolls with the addition of some butter or 
salt. As a drink patient is given oatmeal 



130 LECTURES ON DIETETICS 

gruel and is told to sip it slowly, when real 
thirsty. 

This diet is maintained for the first week. 
During the second week a glassful of wine mixed 
with half a glassful of water and some sugar is 
given warm in the afternoon, while the rest of 
the diet remains unchanged. 

During the third week patient lives on the 
same diet, but leaves off the wine every alternate 
day. 

Schroth's diet may be advantageously 
used in (Edematous swellings and ascites, 
also in arteriosclerosis, omitting the wine, 
however, for a period of 5 days or a week. 
Being a diet much deficient in calories and 
nutritive material it must be employed 
with great care and for short periods of 
time only. 

Very similar to Schroth's diet is 

b) Bulkley's* Rice, Bread, Butter and Water 
Regime. 

The patient lives exclusively on rice, bread, 
butter, and water. 

* L. D. Bulkley : Personal Experience with a Very Re- 



DIET EEOIMES 131 

The rice should be thoroughly cooked with 
water (not with milk). Generally it is better 
to have it dried out somewhat, so as to be flaky, 
by leaving it uncovered on the fire for a while. 
The rice is freshly prepared with abundance of 
butter and salt. It should be eaten slowly with 
a fork and be perfectly masticated. The bread 
and butter should also be well-chewed, to se- 
cure the full action of the saliva. Water, hot 
or cold, but not iced, is to be taken freely, but 
not to wash down the food in the mouth. 

This diet should be kept up for 5 days, 
when an ordinary mixed diet is resumed. 

This rice, bread, butter, and water diet 
is useful in acute inflammatory conditions 
of the skin like eczema, erythema, and 
principally itching. 

(c) Hoffmann's Regime * 

Hoffmann's regime is a coarse vegetable diet 
consisting of brown bread, Graham bread, but- 
ter, potatoes, and all kinds of vegetables contain- 

stricted Diet (Rice) in Acute Inflammatory Diseases of 
the Skin. Med. Record, Jan, 28, 1911. Also Bulkley, 
"Diet and Hygiene in Diseases of the Skin," Hoeber, 
N. Y., 1913. 

* A. Hoffmann : Leyden's Handbuch der Ernahrungs- 
therapie, Bd. I, p. 568 j Leipzig, 1896. 



132 LECTURES ON DIETETICS 

ing much cellulose, principally cabbage; beets, 
beans, mushrooms, salads; peas, lentils (not 
pureed) ; plenty of fruits. 

Hoffmann's regime is best adapted for 
obstinate neuralgias of unknown origin 
and for obesity accompanied with consti- 
pation. It may be kept up for a period of 
two weeks. Then it must be changed into 
a diet of greater nutritive value. 

IV. MILK REGIME. 

Milk is a complete nourishment and may be 
given up to 3-4 quarts daily. The patient will 
best take about a pint of milk every 2 hours. 

This diet is indicated in irritative con- 
ditions of the digestive tract (ulcus ven- 
triculi; chron. enteritis; cirrhosis tiepa- 
tis, and in affections of the kidneys. 

Karell * highly recommended the milk 
diet. He gave during the first week 200 
cc. (Jvii) of skimmed milk four times 
daily. If there were no bowel disturb- 

* Karell: Arch, generates, 1866. 



DIET REGIMES 133 

ances lie increased the quantity during the 
second week to one quart and a half daily. 
Karell's scanty milk diet is useful in se- 
vere neuralgias, in affections of the heart 
and kidneys, accompanied with oedematous 
swellings or ascites. 

v. SOUP DIET. 

Soup diet or liquid diet consists of mixtures 
of nourishment given in fluid form. This is the 
standard diet for all acute febrile diseases, and 
for chronic conditions for periods of time. It 
can be varied according to the requirement of the 
case. Eight to 10 ounces of gruels (oatmeal, — 
barley, — rice or pea — or lentil-flour) alone or 
mixed with half milk every 2 hours can be em- 
ployed in most instances. When it is necessary 
to supply a sufficient nutrition, raw eggs, lactose, 
or butter may be added and should be thor- 
oughly mixed with the above foods. Thus 1-2 
eggs may be mixed in a cupful of milk, or gruel, 
or bouillon; or lactose §ss-gi, or butter 3i-ii 
added to milk or gruels with or without egg. 
Instead of milk kumyss or zoolak or buttermilk 
may be given for a change. Clambroth and oys- 
ter-stew in milk, without the oysters further en- 



134 LECTURES ON DIETETICS 

large the bill of fare. Milk, flavored with tea, 
cocoa, or coffee; lemonade, orangeade, are also 
useful in increasing the variety of the monoto- 
nous diet. 



LECTUEE VIII 

INDICATIONS FOR AND DESCRIPTION OF THE 
METHOD OF DUODENAL FEEDING * 

Duodenal alimentation means feeding a 
patient in such a manner that the stomach 
is kept empty. This can be done by intro- 
ducing a small tube into the stomach, 
whence it passes of itself into the duo- 
denum, and is left there. The main pur- 
pose of this method is that we should have 
the patient always ready for feeding, in- 
dependent of his desire to eat or his aver- 
sion to food. It is easily done. The tube 
can even be allowed to go into the small 
intestine, depending upon the length of 
the tube. 
I have practiced this method for the last 

* Delivered before the Clinical Society of the New 
York Post-Graduate Medical School and Hospital, March 
21, 1913, and published in the Postgraduate, June, 1913. 
135 



136 LECTURES ON DIETETICS 

three and a half years and have treated 
some eighty-four patients hy this method, 
for periods varying from ten to fifteen 
days, — most of them from fourteen to fif- 
teen days. 

The food is usually given every two 
hours, eight feedings a day. The stand- 
ard food is milk (7 to 8 ounces), one egg, 
and a tahlespoonful of lactose. The lac- 
tose sometimes causes diarrhoea and 
should then be omitted. In some cases 
where it is essential to see that there is 
no loss of flesh, butter (1 to 2 drams) may 
be added in every alternate or in each feed- 
ing. This standard diet furnishes 2215 
calories. If in addition, one ounce of lac- 
tose was given that would bring it up to 
about 2695 calories for a grown person. 
If butter was added, it would bring it up to 
3000 and more calories. Only a few pa- 
tients cannot stand the milk, the latter cre- 
ating such a disturbance that it must be 
eliminated. Such patients tell you that 




Fig. 1. — Patient Being; Fed through the Duodenal Tube. 



DUODENAL FEEDING 137 

they never could take milk anyway. Here 
instead of milk, water with barley or pea 
flour can be substituted. Whatever is fed 
to the patient must be of blood tempera- 
ture — neither cold nor hot — strained over 
a cloth, and it must be given slowly. 
When I began to feed these patients I made 
use of an irrigator, letting the fluid run 
in by gravity which would carry it to the 
duodenum, but it was soon found that this 
was very inconvenient. The temperature 
cannot be so well maintained, and the flow 
is either too quick or too slow. It was 
very troublesome, and the patients could 
not stand it, so this syringe was devised, 
provided with a three-way stopcock and 
with this little table (Fig. 2), so that there 
is no need of loosening the syringe from 
the tube each time the former has to be 
filled, and the feeding can be made slow or 
fast as desired. The patients usually pre- 
fer to have « it administered slowly, for if 
given quickly they feel uncomfortable. It 



138 LECTURES ON DIETETICS 

is a very tedious performance, but the pa- 
tients can soon learn to feed themselves, 
and it gives them something to occupy 
themselves with. It requires about twenty 
minutes or so for each feeding, and that 




Fig. 2. — The Duodenal Feeding Apparatus, with 
Table Support. A, Tube leading to syringe; B, tube 
leading to duodenal pump; C, crank; D, tube leading 
to fluid; F, fluid; G, glass; T, table support or shorter 
support. When crank C is turned parallel to A. fluid 
can be aspirated from the glass into the syringe. 
When C is moved parallel to B, the fluid from the 
syringe can be emptied into the duodenum. 



DUODENAL FEEDING 139 

repeated for eight times a day, gives them 
something to do. 

A word in regard to the technical points 
of this method of alimentation. The tnhe 
is put into the throat of the patient and 
he swallows it with water. Care must be 
exercised that the patient does not swal- 
low too quickly, so that it does not rotate 
on itself, but will be taken straight into 
the stomach. Then, a little later, liquid 
food is given by the mouth and tests are 
made from time to time through a syringe 
attached to the tube to see what can be ob- 
tained. If the duodenal pump is still in 
the stomach an acid liquid appears quite 
quickly by aspiration. If the pump is be- 
yond the pylorus, in the duodenum, it is 
very difficult to obtain fluid, for the duo- 
denum is usually empty. The secretion 
appears slowly in drops from time to time 
and shows an alkaline reaction. Another 
point of differentiation is that if we should 
put in air through the syringe, the patient 



140 LECTURES ON DIETETICS 

feels it right away if the pump is in the 
stomach; hut if the tube end is in the duo- 
denum there is less conscious sensitiveness 
and the patient does not feel the air at all. 
If we have to deal with a patient who has 
no gastric secretion it is more difficult to 
determine when the pump has entered the 
duodenum. Here there is no acid in the 
stomach anyway, and in order to ascertain 
whether the pump is in the stomach or du- 
odenum, we make use of different colored 
fluids. For instance, a patient who has 
had no milk, but only bouillon or tea, may 
be given a white (colored) fluid, such as 
milk. If we then aspirate and obtain a 
fluid that is not white, we know that the 
tube end is beyond the stomach. If the 
patient had milk we give him black coffee, 
or any colored fluid that is not white. 

In normal individuals it usually takes 
two or three hours for the tube to go 
through into the duodenum, but in cases 
where we have to apply this method, we 




Fig. 3 
Patient W. S. F. with duodenal tube in the duodenum with empty 



stomach 



„ J . , Th . e X - ray Photographs (Fig. 3 and 4) were kindly made for me by Dr. I. S. Hirsch 
Radiologic to the New York Postgraduate Hospital. 



DUODENAL FEEDING 141 

often have to deal with the pyloric spasm, 
and then it takes much longer. In some 
cases I have had to wait twenty-four hours, 
the longest time being thirty-six hours. 
During the period of the tube passage, pa- 
tient is fed by the mouth with liquid diet 
and tests are made from time to time in 
order to ascertain the location of the tube. 

On the other hand, in cases of achylia 
gastrica, the passage of the tube into the 
duodenum takes place very quickly. We 
test it and find it sometimes already after 
5 or 10 minutes in the duodenum. The 
motility is much greater there. 

With regard to the method of feeding 
again: The temperature must be just 
right. The food introduced must be free 
from thick particles. All the fopd should 
be strained, because in passing through the 
long fine tube it would easily become 
blocked if this precaution were not taken. 
A thin tube is better for the patient. The 
smaller the tube, the pleasanter for the pa- 



142 LECTURES ON DIETETICS 

tient ; but, on the other hand, the more dif- 
ficult the handling of it. Another rule is 
that after each feeding, after the food has 
been given, a little fluid should be thrown 
in and then a little air when the stopcock 
is closed, in order to keep the tube always 
empty. If one is not careful to clean out 
the tube with water and air, the end be- 
comes clogged in a day or two, and the 
tube has to be taken out and replaced, with 
a great deal of inconvenience to the pa- 
tient, as well as to the doctor and nurse, 
and that tube is often spoiled. Where I 
have patients under my direct supervision, 
nothing of that kind happens. It is simply 
faulty technique when that occurs. 

Another point is that while the patient 
has the tube in, his mouth should fre- 
quently be washed out with some good 
mouth wash. If these patients do not eat 
anything, there is nothing to cleanse off 
the surface of the tongue, and it is very es 
sential that that should be kept clean. 





Fig. 4 
F. after the ingestion 



Patient W. S 
stomach. The end of the duod< 
the stomach, in the duodenum 



of a bismuth mixture into the 
tube is distinctly visible outside of 



DUODENAL FEEDING 143 

The tube is left in permanently during 
the course of this treatment. Outside of 
the feeding, the patient is given a pint of 
saline by the duodenal tube. The saline 
may be given either with the syringe or 
by connecting an irrigator to the tube. 
The main point is to let the fluid run in 
slowly and at the right temperature. If 
the patient does not like that, it may be 
given into the rectum by the Murphy drip 
method, for the bowels absorb saline very 
well. The food is the vital thing. By 
this method we accomplish perfect nutri- 
tion and everything is utilized. 

In my first patients I watched the weight 
very carefully, and we found that in most 
of them it was possible to keep them from 
losing weight. Some of them lost, but it 
was mainly due to a loss of water. They 
lost no real flesh, for the nitrogen exam- 
ination showed that under this regimen 
they were able to add to their nitrogen bal- 
ance. It is very important to make the 



144 LECTURES ON DIETETICS 

patients gain a little weight, but not so 
necessary as to keep them from losing 
weight. If we want them to gain, we add 
a little butter to the regimen. 

This method of feeding keeps the stom- 
ach empty and so gives it perfect rest. 
The principle of rest is a very important 
factor in curing disease, and this is an 
ideal method of accomplishing that pur- 
pose. A second point is that very often 
it is essential to accomplish a change in 
the size of the stomach. If it is greatly 
dilated, we can keep it empty, and thus 
give it opportunity to return to its normal 
size. Still another point along the same 
line comes up when we have to deal with a 
dilated esophagus due to cardiospasm. 
While the usual method of treatment in 
such cases is the stretching of the cardia, 
in some instances we find that this alone 
is not sufficient, and that everything re- 
mains in the esophagus. Here we try to 
keep the esophagus empty. We must have 



DUODENAL FEEDING 145 

the food on the other side, and the esopha- 
gus and stomach are kept empty. 

Another point in the same line of sav- 
ing the organ. This method I have re- 
cently applied to the treatment of diseases 
of the liver, with enlargement of that or- 
gan, and .cirrhosis of the liver. The ob- 
ject is to lessen the inflow of blood to the 
portal vein. Everything that is taken 
into the stomach must pass through the 
veins of the stomach and then through the 
portal vein before it reaches the general 
circulation. The capillaries in the stom- 
ach fill up and the veins carry the blood to 
the liver. The same occurs with the blood 
from the duodenum, the esophagus, etc. 
The fluids have to go into the portal vein 
and then into the liver before they reach 
the general circulation. If the liver is dis- 
eased, it is difficult for it to take up the 
amount of blood and exert its functions 
fully. If you reduce part of the inflow, 
much saving to the liver is accomplished. 



146 LECTURES ON DIETETICS 

In the large number of patients whom I 
have watched under this method of treat- 
ment, the results have been very satisfac- 
tory. One of the important advantages 
of this method is that by it we are inde- 
pendent of the will of the patient. "We 
often have to deal with conditions in which 
nutrition becomes extremely difficult, ex- 
treme anorexia, or aversion to food, etc. 
In the case of patients suffering from tu- 
berculosis, kidney trouble, and other con- 
ditions, it is most important to keep up 
the nutrition, and by this method the pa- 
tient can be fed independent of his will. 
He does not have to eat anything, and he 
does not reject his food. Some time ago 
I met a physician, who was quite well 
advanced in years, who was suffering 
from chronic nephritis and who could 
hardly partake of any food on account of 
absolute anorexia. I did not feel like sug- 
gesting this mode of alimentation to him, 
but I gave him one of my reprints on the 



DUODENAL FEEDING 147 

subject. He read it, but did uot apply it, 
aud died about two weeks later. If this 
method of nutrition could have been ap- 
plied in that instance, his life could doubt- 
less have been prolonged. 

The indications for this method of treat- 
ment are: First, ulcerations of the stom- 
ach and duodenum. Second, a great many 
cases of dilatation of the stomach without 
organic obstruction; extreme atony, no 
matter whether there is a pyloric spasm 
present or not. (In many instances I 
have found an actual reduction in the size 
of the stomach under this treatment.) 
Third, in cases where nutrition is difficult, 
nervous vomiting, vomiting of pregnancy, 
etc. One might at first think it would be 
impossible to apply this in such cases, for 
the tube would be vomited, but this is not 
so. 

We at first applied some remedies to 
make it possible for the tube to remain in 
the stomach, but as soon as it got into the 



148 LECTURES ON DIETETICS 

duodenum or further down, the vomiting 
ceased, or the patients only vomited some- 
thing from the stomach; as a rule, they 
do not reject the tube. In many instances 
where there was very severe vomiting, this 
method of alimentation has been the only 
feasible one. A fourth indication, is dis- 
ease of the liver, and still another, fifth, 
is inoperable cancerous conditions of the 
stomach or cardia, where the stomach is 
not closed up and the duodenum can be 
reached. In such conditions this method 
can be applied and bring comfort to the 
patient. 

In one instance I could not make the di- 
agnosis, but the patient had pains all the 
time and could not retain any food. As 
soon as this method of alimentation was 
instituted, the pain ceased, and for weeks 
he was free from pain and was happy. 
When the tube was removed, he was exam- 
ined and found to have a malignant dis- 
ease of the cardia, and later he was oper- 



DUODENAL FEEDING 149 

ated upon and died shortly after, but dur- 
ing all his illness he was never so comfort- 
able as during the time that he had duo- 
denal alimentation. 



INDEX 



INDEX 



Achylia gastrica, 87-90, 
104, 105 
a cause of diarrhoea, 104 
and diabetes, 121 
Acute diseases, diet in, 44 
indigestion, diet for, 67 
Albumin, daily require- 
ment, 17 
functions of, 18 
Alcohol in diet for dia- 
betes, 120 
necessary in food, 17 
Animal diet, intermediate, 
115 
strict, 114 

food, residue left, 33 

vs. vegetable diet. 14 

Antifat diets, 127-128 

Amylaceous dyspepsia, 77 

Apparatus for duodenal 

alimentation, 137 

Banting's regime, 127 

Beaumont on digestibility 
of foods, 30 

Beverages, composition of, 
26 

Bismuth, for diarrhoea, 64 

Bright's disease, diet for, 
65 

"Building up" in cases of 
achylia gastrica, 93 

Bulkley's rice, bread, but- 
ter and water regime, 
130 



Calorie, definition of, 19 
great, 20 
small, 19 
values of foods, 21 

Calories, daily require- 
ment, 21 

Cancer of the stomach, 
diet for, 70 

Carbohydrates, daily re- 
quirement, 17 

Cereals, composition of, 
25 

Chronic diarrhoea, diet for, 
63 
diseases, diet in, 61-66 

Classification of food, 16 

Codein, for diarrhoea, 64 

Coleman, Dr. Warren, on 
nourishment of ty- 
phoid patients, 57, 58 

Composition of most 
common food sub- 
stances, 22-27 

Continuous hypersecre- 

tion, diet for, 82, 83 

Corpulency, 97 

Dairy products, composi- 
tion of, 22 
Diabetes mellitus, 113-124 

diet for, 66 
Diabetes, with achylia gas- 
trica. 121 
with stomach complica- 
tions, 121 



153 



154 



INDEX 



Diarrhoea, acute, diet for, 

68 
Diarrhoea, chronic, 99-112 
from catarrh of small 

intestine, > 99, 107 
from chronic intestinal 

obstruction, 99, 100 
from hyperchlorhydria, 

106 
from stomach disturb- 
ance, 103 
nervous, 99, 101 
Diet, animal and vege- 
table, 14 
in health, 37 
for achylia and diabetes, 

122 
for diabetes, 118-119 
Digestibility of foods, es- 
timating, 34 
Digestion, residue after, 
33 
time required, 31, 32 
Disease, diet in, 43 
Duodenal alimentation, 

135 
Duodenal feeding, indica- 
tions for, 147 
Dyspepsia, diet for, 71-75 
nervous, 84 

Eating, fast vs. slowly, 38 

frequency of, 40-43 
Ebstein-Banting regime, 
128 

Fast eating, 38, 39 
Fat, functions of, 18 
Fats, daily requirement, 

17 
Fever, loss of fluids in, 47 

typhoid, diet in, 53-63 
Fish, composition of, 24 



Food, amount necessary, 
15 
caloric values of, 20 
components of, 12 
composition of most 

common, 22-27 
elementary classifica- 
tion, 16 
estimating its heat val- 
ues, 19 
in duodenal alimenta- 
tion, 136 
tables, 22-27 
Frequency of eating, 40-43 
Fruits, composition of, 27 
Functional diseases of 
stomach and intes- 
tines, diet for, 70 

Game, composition of, 23 
Gastric catarrh, chronic, 

85 
Gout, diet for, 65 
Grapefruit in typhoid, 61 
Graves, on diet for ty- 
phoid, 54 
Grouping foods by physi- 
cal characteristics, 35, 
36 

Health, diet in, 37 

Heat values of food, esti- 
mating, 19 
units of food, 21 

Hoffman's regime, 131 

Hyperacidity of the stom- 
ach, 77-83 

Hyperchlorhydria and 
diarrhoea, 104 

Hyperchlorhydria, diet for, 
78-83 

Indications for duodenal 
feeding, 147 



INDEX 



155 



Injections, saline, 50 

subcutaneous, 51 
Intestinal digestion, 91 

Karell's milk diet, 132 
Kidney troubles, diet for, 
65 



Penzoldt's tables of time 
for digestion, 31 

Physical characteristics of 
foods and their digest- 
ibility, 35 

Pneumonia, diet in, 44 

Proteid-fat regime, 126 



Lemonade in dietary for 
typhoid, 60, 61 

Leyden's theory on typhoid 
nourishment, 57 

Life, origin of, 13 

Liquids, importance of in 
the diet for disease, 
50 

Liquid nourishment, im- 
portance of, 50-52 

Meats, composition of, 23 
Milk in diet for diarrhoea, 
108 
in the dietary of ty- 
phoid fever, 54 
regime. 132 
Mosse's "potato cure" for 
diabetes, 119 

Nature as a guide to ap- 
petite, 44 

Nervous dyspepsia, diag- 
nosis of, 84 

Nourishment for typhoid 
patients, 54-61 

Nourishment in chronic 
diseases, 61-66 

Oertel-Banting regime, 129 
Organic diseases, diet for, 
68 

Pawlow on hyperchlorhy- 
dria, 79 



Reducing flesh, 97 
Regime, Banting's, 127 
Bulkley's, restricted, 

130 
Ebstein-Banting, 128 
Hoffmann's, 131 
milk, 132 

Oertel-Banting. 129 
proteid-fat, 126 
superalimentation, 125 
vegetarian diet, 129 
Residue after digestion, 

33 
Restricted diets, 66 
Rheumatism, chronic, diets 

for, 65 
Rosenheim, Prof., on 
chronic diarrhoea, 108 

Saline injections, 50 
Salisbury regime, 78 
Schroth's dry diet, 129 
Seegen's diet for diabetes, 

116-118 
Sitophobia, 74 
Slow eating, 38 
Soup diet, 133 
Soups, composition of, 26 
Starch, action of in 

hyperacidity, 81 
Starchy dyspepsia, 77 
Starvation methods, error 

of, 46, 54 
Stomach complications 

with diabetes, 121 



156 



INDEX 



Subnutrition in chronic 
diseases, 64 

Superalimentation, re- 

gime, 125 



Tannigen, for diarrhoea, 

64 
Thin people made stouter, 

94 
Tuberculosis, diet for, 62 
Typhoid fever, diet in, 53- 
63 
Dr. Warren Coleman's 
theory of nourish- 
ment, 57, 58 
Graves' treatment, 54 
Leyden's theory of nour- 
ishment, 57 
milk diet for. 54 
nourishment for, 54-61 
solid and semi-solid diet 
for, 56 



Ulcer of the stomach, diet 
for, 68, 69 

Vegetable diet for achylia 

gastrica, 105 
food, residue left, 33 
vs. animal diet, 14 
Vegetables, composition 

of, 25 
Vegetarian diet regime, 

129 
Von Noorden, C, on diet 

for diabetes, 115 
Von Nborden's "oatmeal 

cure" for diabetes, 

119 

Water, benefits of flushing 
the system with, 48 
importance to the body, 
46 

Winternitz's "milk cure" 
for diabetes, 119 



RECENTLY PUBLISHED 

Diet and Hygiene in 
DISEASES OF THE SKIN 

By L. DUNCAN BULKLEY, A.M., M.D. 

Physician to the New York Skin and Cancer Hospital; Consult- 
ing Physician of the New York Hospital; Consulting Der- 
matologist to Randall's Island Hospital, to the Hospital 
for Ruptured and Crippled, and to the Man- 
hattan Eye and Ear Hospital, Etc. 

8vo., Cloth, xiii + 194 pages .... $2.00 NET 
(Sent prepaid on receipt of price) 

REVIEWS 

The important theme in medicine to-day is prevention and 
many an obstinate skin affection can be eradicated only by 
the removal of some underlying systemic condition, partly 
through medicine and oftener through diet and hygiene. As 
a treatise on this subject. Dr. Bulkley's book will be wel- 
comed. IT IS CLEAR, SANE, HELPFUL. 

Journal of American Medical Association. 

The subject matter in this volume supplements the informa- 
tion usually found in theh various standard works on diseases 
of the skin. 

New York Medical Journal. 

The subject of metabolism is looming large in medical 
thought and practice in these days, threatening even to out- 
rank that of bacteriology, which so overshadowed every other 
idea but a few years ago.*** In the book before us Dr. 
Bulkley argues most convincingly that theh origin and cause of 
very many of the common diseases of the skin are dependent 
upon or largely influenced by the nature of the food taken. 

Medical Record. 

Whilst the book concerns itself almost exclusively with diet 
and hygiene in skin diseases, yet the dietary rules offered by 
the author are of such value and susceptible of such a wide 
application, that they might well be learned by all, irrespective 
of the line of medicine engaged in. 

The Urologic and Cutaneous Review. 

PAUL B. HOEBER 

Medical Publisher, Bookseller 
and Importer 

69 EAST FIFTY-NINTH STREET - NEW YORK 






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